Taking Care of Sarah
Sarah’s main meter feeds information to her pump. She also has a spare meter at school.
Sarah never remembers to change her lancet, so I usually try to change it every morning.
Sarah usually uses 1-3 at school, but I always make sure she has a reasonably full vial in her meter.
She should always have two apple juices in her backpack for treating lows.
If you take her out, please make sure she has a bag containing her meter and treatments for low blood sugar.
Only use Glucagon in a severe emergency when she is unresponsive and unable to drink or eat. If you must use glucagon, plan on calling 911 as well
This is a different meter, in kind of a flat black case. It tests for ketones. The only time you’d need to use it is if she is high (over 250) for an extended period of time,or if she’s vomiting.
Important note, if she tests higher than you expect, have her wash hands and test again. Any residue from sweet foods on the hands can cause a high bg reading.
The small amount of insulin Sarah gets continually (is NOT included in insulin on board). Sarah’s basal rate changes dramatically through the day. The point of the basal is to keep her bloodsugar steady when food/bolus insulin isn’t involved. She takes so little during the day that using a temp basal to correct a low isn’t going to help. But she takes much more during the nighttime hours.
The insulin Sarah takes for meals (is used to determine insulin on board). This is based on an insulin/carb ratio (IC ratio) which is different for each meal. We make adjustments when we see she is trending high or low after meals.
120 (1 unit = 120point reduction in bg)
Insulin on Board time
3.5 hours (approximately)
What to make of Sarah’g bg readings...
Nail Biting Zone
Time to totally freak out Zone
(Note, her lowest to date is 43, highest was around 375)
Insulin - Insulin keeps Sarah healthy, but it’s often a precarious balance. She needs different amounts of insulin at different times of the day, and her needs are continually fluctuating.
Sarah’s bloodsugar target is 120, though that’s a really loose target. After a meal she will nearly always spike over 200 (which is normal), and often by the next meal she’s well under her target, usually in the 80-100 range (also normal).
In GENERAL, one unit of insulin will bring Sarah’s bg down about 120 points. - However, that assumes she doesn’t have food working against the insulin.
Sarah’s bg is 95 when she eats a bowl of ice cream at 7pm. She takes 2 units of insulin. At 9pm her bg is 100, her IOB is 1.15 - meaning she still has approximately 1.15 units of insulin working in her body. Well, if her bg is 100 and 1 unit drops her bg by 120, is it time to freak out?
Actually, no, not in this case. Because she ate ice cream, which has a lot of fat, she likely has a lot of FOB (Food on Board) which the insulin is still working against. This is the time to watch and check her again an hour or so later, once the insulin has worked its way through.
Sarah’s bg is 95 when she eats a serving of crackers 7pm. She takes 2 units of insulin. At 9pm her bg is 100, her IOB is 1.15 - meaning she still has approximately 1.15 units of insulin working in her body. Well, if her bg is 100 and 1 unit drops her bg by 120, is it time to freak out?
Yes, you can freak out now. She ate crackers, which are a fast acting carb. Meaning the crackers are probably through her system, but she still has insulin. She’s likely going to drop steadily or even quickly. I would have her eat a small snack containing protein (like an apple with peanut butter), and bolus for it. The pump will deduct the insulin on board when she programs it and in this case probably wouldn’t have her take any insulin. I’d check her about 1-2 hours later to make sure she’s at a happy number.
Daytime - Sarah is very good at caring for her diabetes during the day. She only needs assistance for pump changes and if she’s low. She may need help with carb counting.
Carb counting - The most important element in good diabetes care is accurate carb counting. When in doubt, estimate low; i.e. if a medium apple is 15 and a large apple is 25, and you’re not really sure which one you have, use 15 - it’s better to correct a high later than deal with a severe low.
Keep Foods Simple - The simpler the diet is, the easier it is. Also, if you keep the carbs per meal around 30-50, she usually does much better than a very low or high carb meal. Best meals are things like:
Grilled chicken, peas, 2 crescent rolls
Fish, black beans, 1 Hawaiian roll
Breads - We buy pre-sliced bread so the carbs are on the package
Veggies - Sarah prefers peas, carrots, and kernel corn (dislikes broccoli, green beans, salad)
Meat - She likes meat that is easy to chew, basically anything but steak
Fiber has carbohydrates, but as we all know, fiber is not absorbed by the body; therefore, the carbohydrates in fiber are not absorbed. See the following example for black beans:
Serving Size: 4 oz - 1/2 cup
Amount per Serving
Calories from Fat 9.0
% Daily Value *
Total Fat 1g
Saturated Fat 0g
Total Carbohydrate 25g
Dietary Fiber 6g
If Sarah has 1/2 cup of black beans (1 serving), she will enter a total of 19g of carbs into her pump. The beans are 25g, but the fiber is 6g. 25 minus 6 = 19g.
Most foods have a negligible amount of fiber, so we don’t spent a lot of time worrying about it. However, if you’re giving her foods like beans, apples, pears, or peas, it’s always best to subtract the fiber.
Nighttime. Nighttime is really the only time you should be cautious, because she doesn’t show that she’s low in her sleep. She usually has some sort of a bedtime snack around 7:30, and is in bed by 9:30. If she still has Insulin on Board (IOB), I usually check her bg until the insulin has passed through her system, unless she’s high enough that it won’t matter.
Best nighttime snacks are a carb and protein. Crackers with salami, apples with peanut butter or cheese (If you do crckers with fiber - don’t forget to subtract the fiber). She also likes single serving soups, especially clam chowder. Ice cream is okay as long as it’s Breyers (no high fructose corn syrup) and only a single serving.
Insulin on Board time is 3.5 hours so if you give her a snack at:
Insulin is done
For sleeping I like Sarah to be between 100-130 with no Insulin on Board.
Sarah goes to bed with .25 insulin on board, her bg is 140. She didn’t eat anything high in fat (such as ice cream). The .25 remaining should only drop her about 30 points, to around 110. So you can go to sleep.
Sarah goes to bed with .75 insulin on board, her bg is 140. You check her 30 minutes later, and her bg has dropped to 90 and she still has .5 insulin on board. She’s fast asleep. Set a temp basal rate to -90% for two hours. Check her 30-45 minutes later to make sure she hasn’t dropped dramatically.
Sarah goes to bed with .75 insulin on board, her bg is 140. You check her 30 minutes later, and her bg has dropped to 60 and she still has .5 insulin on board. She’s fast asleep. Wake her up and have her eat 15 grams of carbs - best is either cereal or crackers, but if she’s too sleepy, a juicebox will do. Check her again in 15 minutes. If she’s coming up, keep checking until she’s over 100. If she’s still dropping, feed her again. Set a temp basal rate to -90% for two hours.
This is used to give a correction if she’s high, or determine the amount of insulin on board
Add carbs for food - Sarah does this herself.
Use to reduce insulin for short periods (I do this at night as an alternative to waking her if she’s not too low)
REMOVE THE PUMP FROM SARAH
Prepare new cartridge (I probably have it ready for you)
If Sarah is so low that she isn’t responding and can’t eat or drink, give a shot of glucagon as quickly as possible and call 911. Then call her parents.
If Sarah is high (over 250) for more than an hour or two, check for ketones using the ketone meter. It takes more blood, and we have a limited number of strips, so make sure you got a bleeder before you start.
There really shouldn’t be a time when you need to call a doctor, but if you do, call the Kaiser advise line and ask to speak to the Endocrinologist on call.