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?

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 :-)

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.....

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 3^rd or 4^th 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 :-)

Bad insulin

For the first time in my 16+ years of diabetes I have experienced insulin going bad. In my previous post, I talked about unusually high BG-levels of last weekend that appeared only to be lowered when using my insulin pen for correction boluses. I ended up concluding that it must be due to lacking effect of the insulin sitting in my pump, as nothing was wrong with the tubing or the sites that I pulled out on Sunday and again on Monday.

When I got back from work Monday evening, I changed infusion set - though I had just done that the day before, and the site turned out to be okay - and switched to a fresh vial of insulin. That helped! The last few days, BG has been more manageable, although the heat still does a lot to mess with my levels. Although it is against all I have ever been instructed to do, I have refrigerated the newly opened vial of insulin (I have always been told NEVER to refrigerate opened vials or pens of insulin). I figured that while having this warm summer weather this may be needed if I am not to through out half-used vials again.

F..... roller coaster!

The past weekend has truly been frustrating diabetes-wise. I don't know if it the immense summer heat that Denmark along with the rest of Europe are experiencing at the moment, the reactions of my body being out of wack or whatever. Anyway my BG levels sure has taken roller coaster rides all weekend.

Saturday morning I started out on the low side (2.3 (41)) which made me re-check about an hour and a half after breakfast. At this time I was up to 11 (200), and because I had reasons to believe that I would shoot even higher, I took an additional bolus of 2 U by pen (I don't know why I didn't use the pump for that). At lunch time I was in range at 4.5 (81) and I used the pump wizard to calculate lunch bolus. The pump suggested 4.7 U for my 1.5 slice of rye bread, 1 glass of milk and a small banana (estimated carb count: 69 g). Bearing in mind that I had just finished 8.5 km bike ride for grocery shopping, I figured this dosing reasonable. However, a couple of hours later, I could hardly wake up from a book-reading-induced power nap on the sofa when the phone rang, so I figured I better check the BG. I usually suspect a low, when I have trouble waking up from sleep, and as I was also hungry, I was rather surprised to see a 15.4 (277) result on my meter. I corrected for this, again using my insulin pen rather than the pump, and once again I was back in range at dinner: 4.6 (83). We had dinner at one of Jimmi's colleagues - home-smoked trout with homemade white bread as starter, grilled trout with potatoes and mixed salad as the main course, and homemade ice cream for dessert. Very delicious! The main course and the dessert was about 1.5 h apart, so I thought I might do a quick check to assess the amount of insulin needed for the dessert: 15.6 (281). WTF?!!! At that time, I started to suspect that either the insulin in the pump had gone bad (it was due for a change and fill-up the next day), the site was not working properly or other pump-related issues were causing these crazy sugars. Thus, I corrected with my pen once again - and of course I was low later that night :-/ I checked before going to bed and was 3.5 (63), so I had an apple and went to sleep.

At 9 o'clock the next morning I was 2.3 (41), and because it had now been 12.5 h since my correction with pen, I thought that maybe I was wrong, maybe there wasn't anything wrong with the insulin in the pump, maybe I had just misjudged the amount of insulin needed for the first two courses last night. So I bolused with the pump, and didn't check again until lunch: At 12.30 PM I was 18.6 (335)!! This reading closed the deal for me, and besides taking a correction and lunch bolus with my insulin pen, I also changed the site and reservoir, hoping that this would help. There didn't seem to be anything wrong with the site, or anything blocking the tube, though. The rest of the afternoon and before dinner BGs were fine, 3.9-5.9 (70-106). I had planned to go for a bike ride in the afternoon, but I postponed that due to a thunder storm. After dinner the weather was dry, but still warm and because of all the rain it was rather humid. I went for a good ride on my mountain bike, 27 km, but I ran into a nasty hypoglycemia attack on the way, and I am actually surprised that I managed to get home safely. I do have glucose tabs along with me when I ride, but I just never got around to eat any yesterday, so when I arrived at our home Jimmi was out with the trash and even at distance he could see that I was in need of something sweet and rushed to get something to put in my mouth. I didn't test at the time so I don't know how low I was, but the way I experienced it a good guess would be around 2 (36). Anyway, I started feeling a bit better and hit the shower before hitting the couch to enjoy the strawberry and ice cream (sugar free ice cream) treat that Jimmi and I had agree upon at dinner. I bolused a bit conservative for this, 1.4 U for approximately 50 g of carbs, due to my bike ride which will usually affect my BG both during the night and the next morning. Before going to bed at 10 PM I tested 7.2 (130) which seemed perfect about an hour and a half after strawberries and ice cream.

In the middle of the night (I don't know what time it was, because I did not look at the clock - this is intentionally because otherwise I will have even more difficulties getting back to sleep when my mind calculates how few hours are left before I am to get up!) I woke up, having to go to the bathroom. I usually don't have to get up at night, so this, along with the line of unexplainable highs of the weekend and a dry mouth, made me suspicious. Sure enough: 21.4 (385) - the record of this insane weekend! Again, this made be doubt my pump, and a correction of 5 U was taken by pen. That made me wake up at perfect 5.8 (104), determined that today I will evaluate the function of the insulin in the pump by closely monitoring my BGs after boluses taken by the pump. For breakfast (6.45 AM) I bolused with the pump, and once I got to work at 8 AM I tested again: 3.9 (70). That is a bit too low to work with so I had a small snack of 10 grams of carb, because if the breakfast bolus was working as it is supposed to do then its tale along with the effect of yesterday's and this morning's bike rides will lower my BG even more throughout the morning.

At 9.45 AM I was up to 9.7 (175). Hmm, not quit what I would expect if the morning bolus was working. I usually eat 0.5 slices of rye bread mid morning, so I bolused for this and the slightly high BG by the pump, 1.9 U, and postponed my snack for 45 minutes while getting a sample ready for LC-MS/MS. Out of curiosity, and to get a feeling of the effect of the insulin delivered by the pump, I tested again at 10.30 and got a reading of 9.6 (173). This is certainly not impressive, so I think that I am back to using my flex-pen the rest of the day, and then I will try another vial of insulin when I get home. If that does not solve the problem, I am getting back to Lantus, Actrapid and NovoRapid by injections!

Changes

This morning I had an appointment with my diabetes nurse, Alice. As I mentioned in my previous post, I had several issues to discuss with her. Fortunately, she had time for it. Actually my appointment lasted almost 75 min! We agreed on a few changes to be tested and some habits of mine that I should try to change. The latter is going to be the hardest task as these habits are actually a question about remembering to make some changes that I haven't been used to give much thought to. An example is the use of temporary basals on the pump. This is a function that I have only used occationally, but certainly could turn out to be an advantage on some of my longer bike rides. I haven't been use to pay attention to insulin delivery just prior to a bike ride, because when on injections, I would usually just reduce the last meal bolus before a ride. This I still tend to do, but especially on days when I am low around dinner time and want to take a ride after dinner, a temporary reduction in the basals is likely to prevent hypos during or just after the trip. I will have to work on remembering this.

Alice also suggested that I should pay more attention to, and make use of, temporary basals on soccer game days and the following nights. In the light of that last serious hypo on the night following the last game of the spring season, this may be a good idea. Because I have been using additional Lantus shots on the game days, I have a pattern of much lower basals coded within my pump for these, but I may need to run a temporary lowering of those even so.

As we discussed the issues around soccer games, we also discussed the possibility of wearing the pump during the game. I haven't been very fund of the thought of this, but because of the BG-difficulties I have been having during games, I think it may be worth at least to try it. I got a neoprene case for the pump during sport. It is designed to be worn in a belt, but it should be fairly easy accustoming it for using a clip or something like that in stead. The best place to place the pump during a game seems to be under my arm, so maybe I can just slip it into my sports bra without any clip or other things to hold. I will try it out and see what will work the best.

To eliminate the BG drop that I tend to see in the late afternoon/around dinner, we decided to start with a reduction in my basal during these hours. If this doesn't work we will take a look at the insulin-carb ratio. Alice pointed out that most people, especially doctors - and mine is no exception - refuses to believe that 0.05 U changes can make any differences, but her experience with pumping tells her they certainly do. She encouraged be to make such a reduction in all the basals, if not now then when I had gotten the around-dinner-hypos under control. She had also seen my last A1C and didn't fail to comment upon that ;-) (remember, she would like to increase it to 6.0 %).

Fairly good BGs

The last couple of weeks have been fairly good BG-wise. The majority of my readings have been in target, and the outliers haven't been that far out. I have only had a few low lows (below 2.9 (52)), but I still have a fair amount of readings in the 3.0-4.0 (54-72) interval that I would like loose. I can just accept such readings if they are fasting, first-thing-in-the-morning readings, but they usually aren't. Rather, they seem to cluster in the hours around dinner.

My last HbA1C (3 weeks ago) was 5.7 %, and I would actually have been happy with that if it wasn't because I know that it covers the severe rollercoaster rides that my BG has taken in the 3 months that I have been trying to adjust to pumping. The aim for even testing pump therapy was actually to even out the swings and reducing the number of lows to eventually increase my A1C to 6.0 %. In these months I have had more readings above 15.0 (270) and certainly many more below 2.0 (36) than I can ever remember having in such a short period of time when on injections, at least when using Lantus. I have had two episodes of severe hypoglycemia where I lost track of my actions and needed help from others. Of course I had times of erratic control when on injections, especially the last couple of years that I used Insulatard (NPH) as the basal insulin, but compared to the 2.5 years using Lantus before trying out the pump, I sort of feel that the change to the pump has been a change to the worse. Or at least a change with MANY issues to be solved before being the advantage it was meant to.

I have an appointment with Alice, my diabetes nurse, on wednesday and before that I am trying to write down all the pros and cons of the pump that I can think of. So far the cons lead (12 to 7), although I have a feeling that in the end it will be rather close. I think that I will constantly find new advantages and disadvantages as long as I use the pump, so for now I am just trying to get an overview. In the meantime I hope that Alice will have the time to go through my readings with me. I think that I see a few pattern here and there, and I would like her evaluation of these as well as any suggestions on how to avoid them.

I have a feeling that either I will have to change the settings of my insulin-carb ratio in the afternoon and possibly early evening, or I will have to enter less carbs than I am actually going to eat in order to avoid all the readings below 4.0 that I tend to see at this time of day. It is a bit difficult to figure out though, because I can have a reading of, say, 6.2 (112) mid afternoon at the time where I usually have a snack to keep hunger away until dinner. If I then test 1-2 h after the snack, before I head home from work, I may be at 7.8 (140), which would actually suggest that the carb and insulin calculations are ok, but another 1-2 h later, before dinner, I am likely to be below 4.0 (70). I do have a 9 km bike ride home between the last two reading, and this of course is also likely involved in this drop, but I don't really know how to get about it. I have heard that reducing the basal rates doesn't really have an effect untill an hour later, but I haven't played with that yet. In general I haven't been good at remembering and using the possibility of reduced basal rates when I bike (I also like to go for longer bike rides just for the exercise and fun of it). Maybe it is because I haven't been use to having to speculate too much about adjusting insulin for biking when I was on injections. I would usually only reduce my dinner bolus in the summer because I usually go for my bike rides after dinner. Only rarely have I had to also reduce the basal dose during summer, and when it was needed, only 1 u was cut off. So in order to get as much benefit of the pump as it enables you to, I guess I have to change my way of thinking from the conventional MDI-linked way of action to the CSII one.

Grrr.....!!!

Yesterday, on my way home from work, I suddenly had a flad rear tyre on my bike. At the time I was about 4.5 km from home, travelling at 30 km/h. Fortunately, I didn't crash when my rear wheel suddenly started to "jump around" unabling me to control the bike properly.

Now, a flat tyre can happen, and I probably wouldn't have been so surprised and a bit angry if it wasn't because I, back in November after my first puncture on this new bike, got a special tyre with 1-year guarantee against punctures mounted. I use my bike a lot, and a couple of years ago, when I went to my preveous bike shop for different repairs on my old bike, I asked for the best tyres he could think of to avoid the annoyance of standing with a flad tyred bike. He recommented these special ones, telling me that he had had costumers using the same tyres for several years without any punctures. I couldn't really believe that to be true as the tyres I had on the bike at that time were kevlar tyres that were also supposed to be puncture-free - something they were clearly not. However, I followed his advise, and actually rode on those tyres for almost 2 years without any punctures whatsoever. At the end, the tyres were so worn down the wearing face was almost completely gone. Now I believed in the quality of those tyres!

So, when I bought my present bike last fall, I asked for these tyres again. I was told that the ones mounted on the bike was just as good, but of course I could come in if I had a flad tyre, and have them changed. I had that flad tyre within the first month! Thus, at the first check-up of the bike I asked to get a new hose and one of these special tyres for the rear wheel - I figured I could go a bit longer on the front wheel without having that one changed. Now, yesterday it was my rear wheel that had the puncture so I immediately called the bike shop, telling them that I would have to repair the hose and hand them the bike the next day to have this issue fixed. When I got home and started looking for the injury in the hose, I realized that the bike shop had reused the old hose, because it had the patch on it from my initial repair back in November! It turned out that this old injury was actually the cause of this new puncture, because the initially small hole that was readily covered by a patch had somehow expanded to a 2 cm cut in the hose! I could see that when lifting the old patch. It was difficult to patch up because I didn't have a patch big enough to cover the cut, so i had to put a new patch on top of the old one, and the new patch really wasn't big enough for this either, so I didn't trust this repair to retain its position. Sure enough! This morning I had to stop 7 times on my way to work to inflate the tyre. Grrr.....!!!!

When I handed the bike into the bike shop, he fortunately took care of it in half an hour, but I still had to pay the labour cost of him putting in a new hose. He inspected the tyre, and just as I didn't find any holes in that yesterday, he didn't either, so hopefully it will last untill I have the 1-year check-up on the bike next November. At that time I think the tyre will be so worn down that it will not be safe not to replace it.

Soccer and pumping - additional conclusions

Since starting the experiment on pumping I have had some issues when playing soccer (BG's that piss me off, and Soccer and pumping). My nurse has been convinced that the high BG's that I see after a game, where I have been disconnected for 1-2.5 hours, were mainly due to release of "fight"-hormone (adrenaline) during the game, and not the period of time being disconnected. I was not too sure about that conclusion, though I certainly agree that the adrenaline probably does take part in the high-party. I have found that adding Lantus and Actrapid to my insulin regimen on game days have almost eliminated the problem, which makes me even more convinced that the post-game hyperglycemia issues that I have been experiencing running solely on NovoRapid from my pump and being disconnected 2-3 times longer than recommended in the manual, are not a mere result of excessive adrenaline release. Today at work we had "Activity Day" in our department. This arrangement was arranged by the department's social committee with the purpose of making all the staff and students get together and enjoy a summer afternoon with games and chatting around the barbeque. Thus, we only had to work until noon, and then we all meet outside on the grass for dart, croquet, petanque, vikingespil, soccer, volleyball and foot-tennis. Of course I was up for a soccer game together with quite a few other people from my group. We set up a field on the rough (this part of the lawn is seemingly not mowed as often as those parts were fields were set up for vikingespil, petanque, croquet and dart!) and played two halfs - we needed a break and a drink (the department hosted the barbeque along with plenty of beer and some soft drinks to enjoy before, during and afterwards) :-) I guess that we played something like 30 and 45 minutes, but I really don't know because I didn't check the clock while playing, so it may actually have been longer than that. As always, when playing soccer, I disconnect. I reconnected during our break though. During the second game I didn't feel that fit, suspecting a hypo comming along, so, because I hate stopping in the middle of something, I just consumed half a packet of glucose tabs not leaving the game. When we stopped, I tested just before the barbeque was ready: 3.8 (68). Well, the hypo during the game seemed to be true and I was still on the low side, so I ate some raisins while waiting for the sausages and bread on the two grills to be eatable. About 14.30 PM food was ready. I was not really that hungry as I had an early lunch before the beginning of the activities, but I wouldn't miss the sausages. I only had one though, along with one bread, and figured that a bolus of 1 unit should cover that. A couple of hours later, when getting ready to go home, I tested 9.0 (162). Why??? I didn't really give more thought to it, I was a bit hungry so I bolused 2.3 units (wizard's recommendation) for a bun, ate it and hit the road on my bike. The 2.3 units for the bun is usually more than enough to cover it, especially when going on a 9 km bike ride afterwards, but when I tested before dinner 1.5 h later I was 216!!! By this time I realized that maybe, because I didn't take any Lantus in the morning to cover the periods of time being disconnected during the games, I was probably experiencing the post-game hyperglycemia effect that I have become familiar with since starting the pump. As far as I can tell, I didn't go as high as I have sometimes been following games, which may give adrenaline the honor of throwing the readings through the roof after all, because as the intensity of the games today was not as high as in our games of the tournament, the adrenaline release was probably lighter. Still, I dare to say that this also proves that adrenaline is not the only culprit in this post-game hyperglycemia game, it just does take part.

For the record, by 19.30 PM I was back in range at 4.5 (81) again, so eventhough it required a larger bolus for my dinner this post-game hyperglycemia attack was not as stubborn as previously seen :-) Now it is time for the final reading before going to bed, I hope this one is just as good as the previous one!

My week....

Another busy week has past by. Thursday I had an endo-appointment, which didn't provide any new ideas as to the issues I feel I have been having with pumping insulin. My doctor (MK) did not appear to be that familiar with pump therapy - just amazed of how the pump and infusion site look like nowadays, compared to years ago - and we agreed that I should continue working with the nurse. At the end of my appointment MK asks me if I feel we are getting too close (MK was my co-supervisor during my Master's project, and we have kept contact afterwards because he felt that some of the results I obtained should be published), if I felt I could not talk openly to him because he knew me more than just as a patient and would be more comfortable changing to a new doctor. I was a bit amazed about these questions, although we have discussed it previously, but I told him, as is the truth, that it was not a problem for me as long as we could keep things apart at my endo appointments, i.e. that the time is primarily used to solve diabetes related issues, not experimental or paper issues. That has unfortunately been the case at some appointments, especially if it had been a long time since we have meet scientifically, but this time it was not, and MK agreed to focus on separating the two fields of discussions.

After the endo appointment, I had a 2 H meeting with a clinical professor and his associate professor along with a couple of people from my lab. Our quest was to promote mass spectrometry in general, and particularly our knowledge of this area, to these professors as they had announced at least one opening for a Ph.D. position at the end of this year, something that we would like get into. The meeting went very well, so we are all hopeful that it will result in them hiring at least one of us for projects in the future.

Friday was the traditional Danish Midsummer Eve, where people usually join at bonfires to "send witches towards Bloksbjerg". Jimmi and I had talked about going to the large meadow in Odense where the largest bonfire of the city was set, but we ended up just staying at home for several reasons. Jimmi has just been sent on sick leave from work due to a work-related back injury he got back in December and he wasn't really up to taking the 8 km trip to the meadow just to look at a bonfire when there was World Cup soccer in the television. We also needed to go shopping for something to eat for breakfast the next day. Going to the supermarket for this, we were also determined that at least we would celebrate the evening by buying some fresh Danish strawberries (strawberries and midsummer is closely related in Denmark). So we had our first Danish strawberries of the year along with ice cream - uhmm!!! But first I had to treat a stubborn low that made me get off my bike on the way back from the supermarket, because my arms and legs were not cooperative. Grrr!!!

Saturday was just a quiet day used for house work and a trip to the Rosengaardscenter, a large shopping mall in the south eastern part of Odense. I went there because I didn't manage to go to the pharmacy in the morning, and on Saturdays most of the pharmacies closes at noon, but the one in the mall is open until 2 PM which gave me time to fill a prescription on insulin. They did not have the 3 bottles that my presciption entitles me to get each time, I could only get 1, but that was actually ok because I realized that I had just started all over on the annual medical grant arrangement, meaning that I have to pay full price for the medicine up to 480 kr. (approximately 80 dollars) before I start getting the tiered grant again :-(

Sunday was a very hot and sunny day. We had the last soccer game of the spring season at 10.45 AM, playing on a field properly shielded for the wind by close-grained trees and bushes. That was tough because there wasn't any shadow what so ever on the field during the game, so we felt like it was almost impossible to replenish the water lost by sweating without camel packs on our backs (just imagine how that would look if 22 players were running around with a straw in their mouth from camel packs on their backs ;-)). Unfortunately we lost the game, but overall we can be very happy with our spring season as we stayed in the league that we were promoted to last fall, ending 5 th. of 10 teams.

Whether it was the heat, all the soccer (requiring the use of Lantus to be able to stay off the pump for a suitable amount of time) and bicycling being performed on Sunday or whatever, the night between Sunday and Monday I experienced another severe low. Jimmi woke up at about 1 AM because I was taking up an awful lot of space in the bed. When he wanted to make me move, he noticed I was all limb and sweaty, figuring that I must be low. He started feeding me glucose tabs patiently awaiting my awakening, but it didn't come. After almost an hour and a whole pack of glucose tabs, I still seemed unresponsive so he did a a BG-test that showed 2.3 mmol/l (41). Sure too low, and being worried that all the glucose he had stuffed me with did have any effect, he decided to call 112 (911 in the US). I think that I remember them arriving though, despite I was very sleepy and thus hoping that it was just a dream. Anyway, besides the two paramedics this time there was also a doctor and a nurse along - our bedroom was suddenly quite crowded! I don't know why the latter two had been called, but I guess that I should just be happy about that because it meant that instead of getting a glucagon shot, which tend to make me very sick afterwards, I got IV-glucose in stead, lifting the BG from 2.6 (47) at their arrival to 7.1 (128) at their departure - and I didn't have to go to the hospital. The episode did destroy my night's sleep though, because I could not go back to sleep after they left. I tossed and turned for at least 1 H, feeling like the BG was about to go through the roof - and it was on its way up there being 16.5 (297) when testing, so I did a correction of 4 units and finally fell asleep, only to wake up with difficulty about 1.5 H later with symptoms of being low again. I didn't test, just ate a couple of glucose tabs, lowered the pump basal and immediately got back to sleep - for 1 H then the alarm clock announced that it was time to get up and go to work :-( BG 5.4 (97), though, so that was at least a small victory. These are the time when I really, really HATE this f...... disease - and the inability of me to control the BG just as well as the non-diabetic body can!

Because of the lack of sleep, I was happy that my Monday was not that challenging. I had an ongoing mail correspondence with MK about the paper that I am trying to write - he is reading my draft these days, hopefully providing me with some ideas and critics to go on with - and other wise just did some data analysis before going to a Master's defense at MK's lab in the afternoon. I did not want to go back to work when the defense was over - it is a 30 min bike ride for maybe 1 H more at the computer - so I was back home at astonishing 4 PM! Because of this, we decided to have an early dinner and then head for the movies to see the last movie of the season with our Cinema Club tickets. It was a Danish movie about a guy, Jorgen, being responsible for the lottery club at work. Every time he bought coupons for the lottery club, he would also buy one for his wife, dog-earing it to make sure he could tell them apart. The lottery club usually never win anything, but one day when Jorgen checks the coupons he realizes that they have a full lottery win of 3.5 mill. kr (583,000 dollars). They are 6 guys in the club, so they will each get plenty of money out of this win, yet Jorgen starts to think that he and his wife deserve all the money themselves. This causes them to enter a cycle of lies and excuses about their actions. It wears them down, Jorgen in particular, and he end up telling the other guys of the lottery club the truth. They tell him that he is an idiot, any of them would have kept all the money themselves, and thus it is sort of a happy ending with a clear moral that cheating and lying just doesn't pay. Quite a good movie, also because you could relate to the lives and struggles of the main characters, including the thought about what you would do if you suddenly became a millionaire in the lottery (if you play the lottery, that is ;-)).

Yesterday was plane desk work with a lot of not too encouraging data analysis, which I have continued doing today. However, the biweekly group meeting, which we had today, sort of cut the day in half because it starts at 10 AM and usually takes a couple of hours. This means that you get away from what you have been doing, and for me this made the data analysis I needed to return to even more boring, which is why I am not taking the time to white this long post eventhough I ought to be searching spectra :-) Well, maybe I should just get back to work now!

Another meme

I haven't been too good at posting on a regular basis. I simply haven't taken the time to do it. Work takes a lot of time - even though I sometimes take a break and spent it on the Internet, as just now ;-) - and in the evenings I hardly turn on the computer because I either have soccer practice/games to attend, want to enjoy the decent summer weather we have at the moment, and/or follow the World Cup games on TV (yes, I am a soccer freak, and I do enjoy watching soccer almost as much as playing it myself, although it is sad that Denmark is not among the participants in the current World Cup). Still, I do manage to spent a few minutes now and then catching up on some of the diabetes related blog that I like to read. One of them (http://lalashilolog.blogspot.com/2006/06/highs-and-lows-of-pumping-newbies.html) inspired me to make this post on the "Highs and lows of pumping".

I am approaching the end of the initial 3-month pump-try-out that I reluctantly agreed upon in March. I was set up on April 6 and my now have 2.5 months of experience and learning with pump therapy. As MDI therapy is still fresh in my memory, I cannot help to compare the two regimes.

Highs of pumping:

1. A great advantage when I was in Prague for a conference in the beginning of May. Not knowing was to expect from lunch would have been a bit tricky with injections, as I preferred to use Actrapid (Regular) for meals, thus usually would do the injection 15-30 min. before starting to eat. With the pump it was just take a look on that lunch pack you were handed, estimate the amount of insulin needed to cover it and then GO!
2. Even more flexibility than I had with injections as far as to when and what I eat.
3. Unexpected temptations (food-wise) can be handled - though when on injections, I would usually carry at least a fast-acting insulin pen with me, there have been time where I did not expect to be out during meal time and therefore did not bring any along, thus needing to moderate my intake of food significantly, or simply say no, because I could not bolus for it.

Lows of pumping:

1. Adjusting the basals, parameter for the wizard function ect. is a living nightmare! When I started the pump, I did expect it to take some time before these things were settled, but I did not expect it to take as long as it did - it is actually not settled completely yet, though it is far more acceptable now than just a month ago. I know I ought to go through these fasts in order to check how the basals match my need, and I have completed the night-to-lunch fasts, but it has been hard and actually I ought to repeat them as I have changed the basals in order to get closer to my target range than the initial basal would get me. My problem with these fasts are that I am very active every day so I get hungry if I do not eat regularly. If I am fasting while hungry, I can't focus on what I should be doing (work ect.), which is not very effective. My nurse, Alice, understands this, fortunately, but her colleague, who started me up because Alice was on vacation, did not. She actually suggested that I just lay off some of the activity until the basals were set, but I argued against this for several reasons. First, and most importantly, I can't see how you can use resultsobtainedd on a "lazy day" to regulate the basals needed for usual week days where I bike 20-40 km and/or play soccer practicee or game)! Second, I do not have the patience to commute by city busses to get to work. I have had enough of commuting by train and busses the first years of my study, and as we don't have a car, I would rather spent 25-30 min. on my bike in the mornings and afternoons than twice the amount of time in different city busses to get from my home to work and back again.
   
2. Pumping is so incompatible with my soccer games! I virtually never had any great troubles with game days when using MDI, but with the pump, I have experienced nothing but trouble controlling BG's. I am usually able to start out pretty good, and a few time I have even managed to be in range just after the game as well, but whether or not I am in range just after the match, I can be sure that the BG will sky rocket afterwards. An example: 6.1 mmol/l (110) just after a game, 17.8 mmol/l (320) with beginning ketones and generally feeling lousy just 2 hours later! I am not comfortable with wearing the pump during games, so I disconnect. I also do that atpracticee, which is 1.5 H, approximately the same as a game without the warm-up, and I have no problems with that. I am not sure if the game issue is related to the amount of time being disconnected, fight hormones, or a combination of factors, but I have never had these problems when on injections. The last couple of games I have therefore defied threcommendationsns from the hospital about not involving any other types of insulin when pumping, and taken a shot of Lantus (dose approximatelequalingng 75 % of my pump basal) in the morning and then a shot of actrapid for the last meal I have before the game. I then run my pump basal very low (10-15 %) until the actrapid is out of my system again, then depending on the blood sugar I will raise the pump basal to 25-50 % of normal waiting for Lantus to also leave. So far this has worked nicely for me, having avoided both hypoglycemia before and during the game as well as hyperglycemia afterwards.
3. The pump should in theory even out the swing of your BG, but I havdefinitelyly seen a lot more out of range BG's the last 2.5 months. I know some of them are of cause due to the issues mentioned in item 1 in this Lows-of-pumping-paragraph, but still I am certainly not comfortable with the number of BG's below 2.0 mmol/l (36) that I have obtained in this period of time. I even managed to test as low as my meter just saying "LO", meaning a BG below 1.1 mmol/l (20) - I was certainly not feeling well at that time, and fortunately my boyfriend was there to make sure that I got something to treat that nasty low with.
4. Temptations of delicious and carb-loaded foods can be hard to resist, because bolusing is so easy, not requiring an injection.

This is not a complete list of pro's and con's of pumping for me, but the most important ones for me at the moment. I hope that at least some of the lows will disappear or get less significant by time. I'll let you know what I learn.

Hot, hot, hot

After a week at the Greek island Kos with temperatures above 30 C every day, and difficulties to get temperatures below 28 C in our hotel room at night, we returned to Denmark where temperatures could hardly exceed 18 C during the day. Though we were literally freezing at first, we quickly adapted. However, during last week summer has returned to Denmark, and the last four days this has been with temperatures of 25-30 C. I like summer and sunshine, but I must admit that I prefer temperature not above 25 C, because the air humidity is usually high enough to make the air feel rather heavy.

The hot weather is also - as usual - a challenge for BG-control. I tend to cruise on the low side, but usually I am able to avoid extreme lows by having small meals/snacks every 3-4 H. Sunday Jimmi and I was to take part in a family-get-together-to help-Verner-and-Lotte-shining-up-their-garden. Verner is Jimmi's grandfather, who just had a new hip this winter and therefore is not able to do much gardening yet, so his wife's children had arranged for all the children and grandchildren with their spouses to show up and help with that. We were about 20 people to rearrange the flower beds, paint the garden shed, ect. We started at 10 AM, and as I had just changed site in the morning, I tested before starting the work: 3.4 (61). Hmm, a little too low, maybe due to the 11 km bike ride? I ate a handful of raisins, figuring that to do the trick, and then joined the painting team. We had a short break to eat ice cream later in the morning. I didn't test at that time (I know I should have), just did a small bolus (0.5 U) after consuming the ice. Around 12.30 my boyfriend encourage me to come with him and do a test. I am reluctant to do so, so he almost drag me inside. My memory of it is actually a bit blurred, however I do remember doing the test and seeing the result "LO" on the meter, meaning a BG below 1.1 (20) and thinking "that can't be, I must have used too little blood or something". I can't remember how many glucose tabs I had, but they were followed by a piece of black bread with liver paste. Getting better, I couldn't help being a bit scared by the fact that I actually managed to function, although not that well I admit, and test myself with a BG that low.

Well, I should go back to work. I am analyzing mass spectra at my computer in a very small office that I share with 2 other girls. There is no ventilation in the office and with 3 people and the same number of running computers the temperature is about 35 C, making you sweat even when you are just moving your fingers around the computer keyboard or the mouse.

Off to Kos

I don't feel that I have been at home much this month. When I got back from Prague, I was told that I was hired for two projects in the lab, so I just started a one year full-time position. However, tomorrow, Jimmi and I will be leaving for Kos, a small Greak island for a one week holiday :-)

I am looking forward to a holiday. The weather down there is hot and sunny at the moment with temperatures cruising around 30 degrees Celcius. I wonder how this will impact the insulin in the pump, since I probably will not wear too much close to cover it... I have brought my insulin pens too, though, so if it doesn't work with the pump, then I can just go back to MDI.

I will be back in the beginning of June - with a nice tan :-)

BG's to piss me off

While the week in Prague generally went very well BG-wise, this last week has been a struggle of keeping a steady, and not too low level through the day. I have had too many values below 70, but even when such a value occur before a soccer game, and is treated accordingly, I have not solved the problem about high BG's afterwards. I find it incredible annoying, not to be able to keep it in range even when it's fine after the game. Mostly, I will be a little high afterwards, probably due to being disconnected for more than 1 ½ hour. For instance, we had a game in the weekend. I was low (2.9 [52]) before going out, so I had a four glucose tabs and a dried fruit snack to cover that (it was only about 1 ½ hour after lunch, so the bolus for that was still active in my system). After thoroughgh warm-up, I got the first half (45 min) of the game on the field. When being substituted at half, I reconnected and watched the rest of the game from the side - with the rain soaking us and temperatures around 12 C with a good wind to make sure we would cool down quickly! After the game I tested 12.3 (221), which I did not really get, but anyway, I took 6 units - something that would normally drop me almost 18 mmol (320), but when I retested before dinner an hour later I was up to 14.6 (263). Grrr! Why?? Being quite angry with this apparent "insuliresistancecsyndromeom-following soccer-games", I bolused 9 units for the dinner, which of course send me down in the 4 (70)-range later in the evening, but it appeared to work because I went to bed with a BG of 5.5 mmol/l (99) and woke up at 7.2 (130). Anyway, I have tried different alternatives to deal with the usually higher BG's after a game (I have managed to land at 6.3 (113) after a game, only to sky-rocket to more than 17 (306) only a couple of hours later), but so far it hasn't really worked satisfactory. I must admit that I am a bit puzzled about it, becauspracticese (1 ½ h) is usually no problem at all. Because of this I don't really think that it is just a matter of hormones (adrenaline) with the games. I have tried using Lantus like in the un-tethered regimen, but that did not really do the trick, so now I am actually considering involving Actrapid (Regular) before games, because I am used to handle that, but it does annoy me to have to grope through the darkness in order to find a stable solution, not to mention the reluctance of my diabetes nurse to the fact of involving other types of insulin than the NovoRapid given by the pump. So any ideas, comments or experiences on how to deal with sports when disconnecting, would be highly appreciated.

Tour de Prague

Walk on Charles Bridge in daylight

The trip to Prague was not all business. We did have time to enjoy the beautiful city. Wednesday we spend the whole day sightseeing. We started out heading for Charles Bridge (Karlov Most in Czech), to see it by daylight. On our way, we encountered an exhibition of sculptures in one of the city squares (see pictures).








Me at a sculpture outside a historical building

Some of the sculptures of one of Pragues squares

Charles Bridge and its surroundinggs are totally different in daylight. The bridge is crowded with tourist, street vendors, and beggars. We crossed the bridge to go to the other part of town with the castle and president palace. It took a lot of steps to get up to the castle, and at the top we stopped at a stand with a sign encouraging people to contribute to a project that should give mentally ill people of Prague better homes than the hospital they are currently staying at. For 100 Czech koruna (equals approximately 25 Danish kroner or 4 dollars), you would by a clay brick that would be used for the chimney or stone tracks at the building. We bought 2 bricks, decorating them for others to see that delegates of KMEB, Odense, Denmark contributed to the project ;-)

We visited a couple of churches on our tour, and here we experienced how groups of tourist, sometimes young people, other times older ones, would suddenly arrange themselves in rows with a conductor in front of them and start singing, testing the acoustics of the church. As soon as they finished their great performance they would disassemble as quickly as they assembled in the first place, looking like a group of tourists and not an awesome choir. Amazing!

In afternoon we headed back to our hotels to prepare for the welcoming ceremony of the congress that we were attending. We wanted to put up our posters at that time too, and as the others had posters printed on fabric, these needed to be ironed. My poster was printed on photo paper, and when the other posters had been ironed, we rolled these up around my poster to carry them all in the tube mine was kept in. The welcoming ceremony was about an hour in length, followed by a reception. Having walked a lot that day, all of us could feel our feeds at the reception, but it did not stop us from going out for a late dinner afterwards - only using the metro to get from the congress center to the center of the city, otherwise walking :-). The next day we were gifted with pedometres from one of the companies in the exhibition area of the congress. The company had a competition where delegates wearing the pedometres could come to their stand to show how many steps they had walked in a day, and if enough win a price. Learning this, we couldn't help being a bit annoyed that we had not had these pedometres when we went sightseeing the day before :-)

Back again

It has been a while since my last post now, due to the conference that I had to attend in Prague, but this just means that there is so much more to blog about now :-) The last days up to our departure was rather busy with meetings, poster finishing and printing and so on, which is why I didn't get to post anything during those days. We set off for Prague last Tuesday, having to catch a train at 7.30 AM in order to get to the airport in time. We arrived in Prague in sunshine and 23 C, and managed to find the right bus, to take us to the metro to get to the center of the city where our hotels were located. Now, even though the bus departed from the airport carrying many tourists, the information given through its loudspeakers were in Czech, which neither of us had any knowledge about. We knew where we had to get of, but because that was at the end station, and both the information about where the bus was heading as well as the name of the next stop was given through the loudspeakers, we misinterpreted the information and got off to early. Standing at the bus stop, we quickly realized that and luckily the next bus would arrive 10 minutes later, so in the meantime we laughed a bit of ourselves while we "synchronized" our mobile phones, so that if we were to get away from each other later on, we could send an SMS or call. We joked about picking up our boss, Moustapha, and his assistant research professor, Basem, who would arrive the next day, and getting them off the bus at the same stop to "synchronize" their mobile phones as well :-) We didn't do that though.

The whole KMEB delegation at a late dinner Friday. From the left is Jorge, me, Basem, Sijranke, Pernille, Moustapha (our boss), and Moustapha's wife, Mette. Amer is behind the camera.

Standing in the center of Prague with all our luggage, our first quest was to get hold of a city map to help us locate our hotels. We were 5 people, two guys and 3 girls, but we had not managed to get the same hotel for our stay, so the guys would be in one apartment hotel, while Pernille, Sijranke and I would be in another apartment hotel. It took us a while to actually get hold of a map, and still we had to ask for the way to our hotel. Because we were approaching 3 o'clock in the afternoon, not having had lunch yet, we decided to drop the luggage in our hotel, go get some lunch and then find the guys' hotel afterwards. After this late lunch, we went shopping for breakfast the next days (breakfast was not included at any of our hotels, but as both of them were apartment hotels that didn't matter much, because we had kitchens to prepare our own breakfast in), and located the guys' hotel, which turned out not be very far away from our hotel. After getting settled in our hotels we went out to look at the beautiful city of Prague by night.

Sijranke, Amer, Jorge, and Pernille standing on the Charles Bridge of Prague

Me, Jorge, Pernille, and Sijranke at Charles Bridge the first night in Prague

The conference officially started on Wednesday 10 May, but having looked at the program, we decided that clinical lectures that were on, did not really have our interest, so we went sightseeing in Prague the whole day instead - I will tell you about this in another post. We registered at the conference in the evening to attend the welcoming ceremony and reception, though, as well as to put up the posters of our scientific work.

Me at my poster

With this I will end the first part of the "conference in Prague"-tale, stay tuned for the parts to follow :-)

Soccer and pumping

The past weekend was pretty busy. Saturday I had an away soccer game in the afternoon, and Sunday we had to go to the confirmation party of Jimmi's cousin. In this program I had to try to fit in at least 1 overnight-to-lunch fast for the nurse to evaluate my basals at the appointment today. I started a fast Friday night, but had to stop for "lunch" at 10 AM, because I started feeling really hungry and thus decided to test: 3.4 mmol/l (61). Despite eating well and cutting back insulin, the low trend continued and I was only 2.7 (48) when I tested before preparing for the game. Grrr...! Well, glucose tablets and my preferred carbohydrate-containing sports drink of orange juice and water 1:1 (I prefer to just drink water when I practice, but when needed I have found this combination of juice and water to be useful) in combination with the fact that I always disconnect when playing soccer did the trick and I landed at a satisfactory 6.4 (115) after the game. I didn't eat anything at that time because dinner was just about an hour away and I didn't want to spoil my appetite for Jimmi's chicken roast ;-) During dinner I started feeling uncomfortable, though. In the beginning just tired which I thought was just due to the game and bike ride, but then a subtle nausea started showing its ugly face. I didn't finish the meal that I had bolused for but hit the sofa instead. As I didn't feel better and also started feeling thirsty, I suspected that the BG was not where it ought to be. Surely not! At 7 PM, just 2 hours after being 6.4 upon more than 2 hours of soccer, I was 17.7 (318) with ketones starting to show up :-( Based on my experience with a leaky tubing earlier that week, I decided to do the correction with a pen, just in case this was a pump and/or tubing issue once again. I had just done the correction and tried to drink some water to quench my growing thirst when my dinner decided it was time to resurface! Why does such things always happen after you bolused/corrected? Needless to say, this meant that my BG's cruised rather low the rest of the evening, but luckily I managed to pull through without help from others. I discussed the episode with the nurse today, as this was exactly one of the precausions that I have had about pump therapy. She couldn't explain what had caused it, and I really have no idea either. I can't say that it couldn't have happened with MDI's, just that I have never in my more than 16 years with this experienced anything like it. It is my general experience that my BG will rise after soccer practice and games if not compensated with insulin, but I have never experienced such discomfort due to a BG that has only been high for a short amount of time. Only with continuous high BGs as at the time of my diagnosis and the end of my honeymoon period, did I feel that unwell.

Apart from the issues mentioned above and in previous posts, I am slowly adjusting to pump therapy. I actually enjoyed being able to go through the 3 course-menu lasting more than 4 hours at the confirmation party without having to either inject several times or risking to bottom out between courses. The next big test for me will be a trip to Prague next week. I am going to a conference on calcified tissues, presenting a poster with some of the results of my Master thesis - details will follow :-) The nurse provided me with a pump certificate today to circumvent problems at the detectors in the airports. They are actually still working on making this certificate more convenient. For now it is just a bunch of papers that can be cut into smaller pieces and fitted into plastic covers about twice the size of a credit card. Most of the pages are in Danish, though, being more like a short guide to the pump user. The language of the certificate written in English is quite poor and not that informative yet, but I guess that it does contain the most important information about the pump being a medical devise that is not to be taken away from me, and a referral to the Endocrinology Unit at the hospital in case of doubts.

Pump issues

As mentioned in one of my previous posts, I have agreed to try an insulin pump for 3 month. My diabetes nurse has tried for years to convince me about this, but it was a combination of several things that finally made me say, "okay, let get it over with then":

1. my boyfriend suddenly turned around, thinking it would be a good idea - so now the pressure was on me from several directions!
   
2. the fact that maybe, if pump therapy should really improve my daily regulation, now would be a good time to test that in order to finally be able to convince my boyfriend that going to Denver to do a Ph.D should not make him worry, if I deside to do that, even if he does not feel like going with me
3. I am going to a conference in Prague in the beginning of May, and this would enable me to test and compare the challenges of travelling with a pump vs. pens

The reasons why I have been reluctant to try the pump were not that I could not see some advantages and posibilities of this sort of therapy, but mainly the fact that I could also see some disadvantages and difficulties of it, which didn't really excite me. A few of the latter mentioned have turned out to just be prejustices, now that have been pumping for almost 3 weeks. However, yesterday reinforced another of my pump prejustices: The one about the need to test frequently and ALWAYS have a back-up plan at hand. Yesterday started out okay. I was 7.8 (140) before breakfast, and I used the bolus wizard to estimate the breakfast bolus of 5.6 U. Because I have not come to trust this wizard function completely yet, and because I had a suspicion about being too high later that morning, I tested again about 2.5 h after breakfast: 17.1 (308)! WTF!!??? Although I suspected that I was high, I did not imagine I would be that high. While evaluating posible reasons for this, I took a correction. I inspected the site, wondering that it looked a bit moist, but maybe that was because I had been sweating a bit on my bike ride to the university earlier that morning. When the pump had given the correction I inspected the site again, though, and I wasn't pleased with what I saw! Now it was clearly wet and the smell of it let no doubt that the site was somehow leaking! Great, just one of my precausions about pump therapy had been confirmed. I did not have another infusion site at my desk, but fortunately the pen that I used to use beforehand was still in its place, so I turned to that instead. However, I had no idea how much, or how little insulin had actually been delivered by the pump, so I would have to guess on the correction and the bolus for lunch later. That went fairly well, though, despite going low before lunch (3.0 [54]). The rest of the day I debated with myself about whether to insert a new site when I got home, just prior to leaving again for soccer practise, or just leave the pump off until this morning. I was seriously tempted to do the latter, but I ended up inserting a new site when I got home anyway, and fortunately it seems to work as it is supposed to (*7-9-13*). I can't help wondering about how sane it actually is to miss injections!! You woundn't think that would be a posibility, having cursed the inconvenience of them on and off during the last 16 years ;-) Still, the experience confirms that the pharmacy that you have to bring along when on the run will be even more voluminous when using a pump, and I must admit that I think that I will rather carry the pens along with me than having to carry extra infusion sites, syringes, insulin bottles and so on. After all the pens easily fit in a pocket or a bag, while the pump supplies will require cargo pants with multiple large pocket or a bag with a compartment dedicated to the supplies to cover prospective issues of insulin delivery :-)