Scary 4am Low: A Cautionary Tale

I’m a little rattled this morning by the events that played out last night when I should have been sleeping peacefully.  I’ll do my best to convey them here now:

I went to a holiday party last night and both drank and a ate a bit closer to bed time than I like to; it seems the food in my stomach when I’m sleeping digests a bit quicker and I tend to spike a bit higher than I might if I didn’t go to sleep so soon after eating.  I also walked home from the party and was seeing double down arrows on Dex and a BG of 175 which from experience I knew would either level off at 175 once I stopped walking/went to bed, or would continue to raise one I went to bed and super-digestion commenced.

So, I went to bed last night expecting a bit of a BG-coaster but after a comedy of errors, what I got was so much worse.

Here’s what I remember:

Around 4am, I hear M asking me if he should get me some orange juice. I must have been feeling the low at that point because M usually responds only to my squirming and not to the sound of Dex. I also must have been pretty low because when he asked, rather than saying “no” like I normally would do and getting the juice myself, I said “please” and I put my head on the pillow and let the cold sweat drip over my skin.

He brought back a full, tall glass of orange juice (at lease 4x what I would normally use to treat a low) which I drank in two gulps.  He got a second glass that went down just as easily.  I lay there for a couple minutes to try and let the juice absorb when I decided to actually look at Dex.  58 mg/dL.  Not too bad. But 58 wasn’t really a good description of how I felt. I felt sub-zero. So I grabbed my meter and checked.  32.  That’s more like it.

I went into the kitchen and ate a few spoonfuls of pistachio Haagen-Dazs and Nutella.  M came to check that I was ok and laugh and my standing in front of the open freezer with a carton of ice cream and a spoonful of chocolate.  I went back to bed and back to sleep.

In the morning, I assumed I would be sky high but Dex was only reading in the 120’s.  A check with my meter confirmed it.

7 am BG after overnight low.

7 am BG after overnight low.

WTF? Where’s my sky high BG that should have followed my massive 4am consumption?  Looking at Dex confused me even more – this low occurred after a rapid drop in BG at 2am.  I must have awaken to the sound of Dex alerting me to a high and I must have groggily corrected my BG of 185 (as determined by Dex) and corrected with a bolus from my shiny new t:slim pump.  (Now, I know I shouldn’t be correcting from my Dexcom, but I do. And I’ve found it to be reliable enough and even when it’s not the outcome is generally not so far off to be a problem. Generally.) This is the sort of overnight correction I am in the habit of doing, and doing it is barely a blip on my radar and happens mostly on autopilot.  So, I decided to check my pump history to see if this was the case.

t:slim history screen showing a surprise.

t:slim history screen showing a surprise.

Looking at the above image, I was shocked.  I initiated a 15 u bolus at 2:24 in the morning.  Why?  Purely by accident apparently.  The t:slim displays 3 things for every bolus: the time at which it was completed (boluses can be a bit slow, in this case at 2:48 am), the time it began (2:42 am) and what was entered to initiate the bolus.  See in the picture it says “B: Food/BG” then “183 g/NA”?  This means I bolused at 2:42 am for 183 g of carbs rather than a BG of 183 mg/dL!  What should have been 2 u was 15 (max bolus allowed by my pump settings).

How can I make such a stupid mistake? I’ve only been using the t:slim for about a week and I love so many things about it, including that I no longer have to dial in  the units for a bolus.  However, dialing in that number has always provided me with a check that I couldn’t ignore before delivering a dose of insulin. The t:slim asks me 3 times before delivering a dose; it does a good job of shoving information in my face.  What it doesn’t to is engage my brain enough during autopilot to help me see the error of my ways.

This is what you see when you initiate a bolus with the t:slim

This is what you see when you initiate a bolus with the t:slim

The bolus screen clearly indicates where to enter a BG and where to enter carbs.  However, once you click, the next screen is nearly identical for each:

BG or carb keypad

BG in carb windowBG in BG window Keypad; BG in carb window; BG in BG window

Once the numbers are entered, it displays a calculated dose then you hit “next”, confirm twice, and done.  The bolus initiates and the pump vibrates quickly upon completion.   With auto-pilot initiated, I entered and confirmed and was asleep long before the vibration.  End of story.

So.  What have I learned?

  1. The obnoxious dial-a-bolus method used in all other pumps may have irked me most day,s but it did provide me with a mental check that probably would have prevented this from happening.
  2. Actually using my meter to confirm my Dex BG would probably have taken my brain far enough out of autopilot to notice my mistake and prevent this from happening.
  3. For some reason, my first instinct when I go to calculate a bolus is to click on the left most box first, and when my brain is in BG mode instead of carb mode, there is potentially a problem.

I started with the t:slim about a week ago.  While I am still smitten by it, I’m realizing I need to approach this change with a bit more caution that I have been.  I’ve had Animas’ pumps for about 12 years and I can use one with my eyes closed.  I’m going to have to spend some time focusing more on D and destroy my old auto pilot (or at least reprogram it).

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Shapeways 3-D Printed “Brixometer” Dexcom Cover

After having (and wearing out) a couple of silicon sleeves I adapted to cover my Dexcom G4 receiver, I started looking for another, even sturdier option.  Eventually I stumbled across a TuD convo about 3-D printed Dexcom covers.  For under $15 (plus shipping) I now have this form fitting hard plastic cover that was 3-D printed just for me.  (Well, it’s made to order so that’s kind of like it was made for me, right?)

Dexcom Cover

It fits my receiver like a glove, has a slightly textured surface giving it a pretty good grip, and is open on the end to allow easy access to the charging port. (Or, if your sliding charger port cover has fallen off like mine has, you can simply turn this case around and it will fit in the other direction and cover the port when it’s not in use.) Plus it has this nice pattern of holes intended to lighten it and add grip which also give it a nice black and white polka dot look (that I kind of love).

Dexcom cover

As of now, I haven’t had it long enough to comment on durability but I’m feeling pretty good about it so far – the girl who originally posted about it on TuD claims she’s had hers for a few months and it’s holding up well.

To get your own, follow this link to the listing on the Shapeways website.  I bought the “White Strong & Flexible” variety but it can also be purchased in a few other colors and a slightly smoother texture as well.

Shapeways.com

Dexcom Skin, sort of

After stumbling upon this thread at TuDiabetes, I went ahead and purchased an Insignia Pilot silicon case for my new G4 Dex.  The dimensions of each are pretty similar (Dex G4 = 101.6 x 45.72 x 12.7 mm, Insignia = 100.0 x 49.20 x 11.1 mm) and each has a rectangular screen with circular controls.  I held the G4 receiver up to the screen to visually compare, and I figured the circles wouldn’t line up perfectly, but it looked like they’d be pretty damn close.   (I’d also like to note that I ordered this one specifically, and it came with a second case in black, pictured, and a removable belt clip and arm band all for only $4.87!)

Dexcom G4 in Insignia Pilot case

Close, but not good enough!

As you can see in he photo, the alignment is somewhat worse tan I had hoped for.  I lived with it this way for about a week, and then this happened:

Dexcom G$ receiver in modified Insignia Pilot case

Take that!

The result is a somewhat wonky solution that adds traction to the receiver so it stays firmly planted in my jeans pocket, and cushions it a bit when it does manage to fall.  Since the case is made for an entirely different device, and I’ve cropped out a bit of the structure, the receiver is very easily removed, but that doesn’t really bother me.  Plus there’s the added bonus of a conveniently located window perfectly framing the charging port.

Dexcom G4 receiver in Insignia Pilot case

Another happy coincidence.

I’m still hoping Dexcom will get there act together and sell a snugly fitting case designed just for this receiver.  But until then, this may be the perfect solution.

G4 Platinum (aka The One with Terrible Photography)

I have nothing but love for my new G4 Platinum Dexcom system.  Here are a few bulleted points on the matter:

  • Smoother lines.  I’ve seen some discussion in the DOC about the new Dexcom varying from the old.  Personally, I see this as a plus.  If the new behaved exactly like the old I would assume that no improvements had been made.  The pic below shows the same 24 hour period (7+ on my arm, G4 on my thigh) and you do see differences in the graphs.  Looking at these from a purely analytical standpoint I would conclude that they are presenting me with the same data, but the G4 has a better signal to noise ratio yielding a smoother and more accurate graph (I can’t, however, say for certain if this is due to differences in sensor placement if it is real).
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How’s this for a double (almost) no-hitter!

  • The wire is visibly narrower (sorry no picture) which means a more comfortable insertion/wearing experience.
  • I ❤ the color screen (aside from being somewhat more difficult to read in the sun):
20121209-084512.jpg

Yay for color screens!

  • Smaller – fits more discretely in my pocket.
  • No silicon cases therefore, more likely to slip out of my pocket.  This is a bit of a problem but will hopefully not result in a receiver in the toilet incident anytime soon.
  • Back to accuracy:  G4 – 140 mg/dL; 7+ – 142 mg/dL; Freestyle – 144 mg/dL (taken about 8 hours post-calibration in the AM).  Can’t complain.

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  • Getting new D-gadgets makes me a better diabetic (at least for a little while)…

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  • Can anyone tell me what the right arrow button is there for??  I’m certain that I have not once had reason to push the left arrow.  This irks me.

It’s here!!

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It’s here! It’s here!!! I began the process to upgrade nearly a month ago but it’s finally here!

Funny story, I was tracking the package obsessively as it made it’s way from San Diego to my workplace in MA and I knew that it was to be delivered by FedEx today.  My good friend, B, who manages the shipping and receiving department, assured me that the truck comes at 10:30.  So, of course, I check the tracking info at precisely 10:35 to find that Delivery Failed! Business closed/Recipient unavailable. Delivery will be attempted on next business day. And, of course, I began telling everyone who would listen.  At 11:45, I left lab to have lunch/call FedEx and tell them how disappointed I am by their actions (we were clearly NOT closed!) only to find the box sitting nicely on my desk.  (Yay!)

I learned an important lesson today; do not check FedEx tracking precisely 5 min after a scheduled delivery time.  Wait at least an hour.

I suppose now I have to update my blog header with a new photo…