I put on my detective badge [I always dreamt about becoming a detective] and I line up the usual suspects:
No 1: HUMAN ERROR
No 2: EQUIPMENT FAILURE
No 3: BIOLOGICAL SABOTEUR
No 4: FORCE MAJEURE
First: HUMAN ERROR [H.E]
Me: [not beating about the bush] Are you to blame for this high BG?
H.E. Why do you always blame me FIRST?
Me: Because YOU have the biggest margin of error!
H.E. OK, but are you sure the hands were clean for the test?
Me: OF COURSE! Even little kids know that you need to wash
and dry your hands well before you prick the finger!
H.E. OK, I see you mastered the basic rules. However, let’s see:
WHEN did you check the BG? Has it been X* hours after the
meal and bolus, or did you rush again to see what is happening
an hour after the meal? You have to wait for the time of
insulin activity to pass, you need to give it a chance to do the
Me: Aaaaaaa, I knew you would ask that! Of course I waited 3
hours* after the bolus, but see, the BG is still too high. Wait,
could it be that I didn’t count the carbohydrates correctly? Did
I miss something he ate?
H.E. It is possible, very probable! He either had more food
with carbs than you bolussed for, or you counted the carbs
correctly but the insulin: carbs ratio was not right. Quick then,
go and write down everything Mr T ate, add all the carbs,
check how much insulin you gave, check what ratio it makes.
If it turns out that the error was there, at least you will know
for next time, not to repeat the same mistake.
*different insulin(s) have different duration of activity
Second suspect: EQUIPMENT FAILURE [E.F.]
Me: [I have to frisk-search this one]
- Just in case, I check the BG once again, who knows, may be the
meter went berserk.
- I check the infusion set, visually: it has not detached, looks OK.
- I check history on the pump – when was the last time I changed
the set? That tells me how old the set is. Usually it gets tired
after three days and that is about the time that the body starts
rejecting it too.
- I check if the pump had any alarms recently [I would have heard
it though] – no alarms about occlusion or suspension
- I look for bubbles in the supply line – they usually appear after
jumping, when one moves from cold to hot and vice versa, but
most commonly the first day after filing a new insulin reservoir
[there are always lots of micro bubbles stuck to the wall of the
reservoir and we cannot always get them out while filling the line
the first time]
Me - Thinking: When Mr T was on pens, this part of the investigation was much shorter: you check to see if the needle was blocked; squirt out some insulin into the air and thats it, keeping in mind that it could have been some air in the cartridge that went in instead of insulin, although no more air is visible now.
Hmmm, there is one other possible [E.F.] which I can not check: I question if the insulin has lost its potency? How long has it been in the reservoir, away from the fridge, next to the body?…. They say, in summer, it is possible for insulin to loose its “powers” if it was exposed to higher temperatures for longer. It has not happened to us so far.
NOTHING then, OK. I move on: NEXT!!!!
Ahhh, this one, BIOLOGICAL SABOTEUR [B.S.] is a very sneaky one. It likes to operate behind your back, you cannot detect his moves, you can not blame him for anything with certainty. You can only ponder and guess:
- Could it be that the tissue at the current infusion site has got saturated and has lost its absorption capacity? Are there any tissue lumps there?
- Could it be a virus attacking the body, rendering insulin ineffective?
- Could it be some of those seven or eight hormones secreting in secret, all of which make insulin’s action weaker? Adrenalin, growth hormone, who would know them all…
Got sidetracked. Lets see, where were we…….
NEXT: FORCE MAJEURE [F.M.]
This one is a complete mystery! Very little is known about him and his affect on BG. It is believed that significant change in weather conditions , change of seasons and who-knows-what else fall into this category.
Well then, those were all of the USUAL SUSPECTS. Hmm, I recap quickly:
If it isn’t E.F. [Equipment Failure], regardless which one’s to blame out of the other three I have to give a corrective dose of insulin. Without the delay!
Then I wait for the period of activity specific for that insulin to pass and test BG again. Mr T already knows that it is good to drink extra water when BG is high, to wash the excess off, to prevent dehydration, to prevent ketones accumulating. There he is getting some water at the sink, that’s a boy!
I test again, BG did not drop! Its’ the same, high! That’s enough! There is no further, third chance for that suspect No 2 [E.F.] equipment stuff up! I change the infusion set and line, I fill the line making sure no bubbles are left in it. I prime the new infusion set [cannula]. This time I do not suspect the weak, old insulin, so the old reservoir is spared.
I correct again, wait…. and test again…..
And so, the BG returns to calm waters. I take off my badge and rest for now, until the next surprise, until my next detective assignment.