40 mg/dL
We had one of those days this week that shakes you back to reality. You can never let your guard down with this disease, not even for a second. Even with all the technology and safeguards in place, T1D still has a mind of its own. Many times we get a false sense of safety with the CGM, but this experience reminds us that it's a tool and not at all the reality of how the kids are really doing. Ollie and Walker have an incredible support system at their school: a clinic aid who is one of the most wonderful people I know, teachers who know the children and all their little quirks, friends who care for and advocate on their behalf, and a community that understands and watches out for others. Without all this it could have been a very different day.
Walker has been fighting a bit of a cold for the week, and because of that her blood sugar has been trending high. We've been working hard to keep it down in range, but the cold tends to fight us every step of the way. Wednesday morning she had a site change for her pump, and a healthy breakfast, and was shipped on her way to school. She was still a bit high before I dropped her off so I corrected her with a bolus of insulin, nothing too extreme but just a bit to bring her down. I watched her CGM graph while I taught my 7th grade class and noticed she was beginning to come down at a slow rate. I was comfortable with the change and happy to see her body was responding to the insulin. Her clinic aid, Nicole, stopped in to my classroom and we chatted for a bit and she asked if I was comfortable with her number. At this point she was 120 and her number was trending down, but still at a slow rate. I said I was very comfortable, knowing she was in the classroom most likely doing her main lesson work and sitting at her desk. She would be eating snack in less than a half hour and Nicole would be checking and bolusing at this time. She agreed that she was also happy to see her in range and thankful she must be feeling better now. Nicole left and I went back to my work (I was on a break from teaching at this time). Twenty-five minutes later I receive a text, as I always do at the kids' snack and lunch times. I looked at the Dexcom app on my phone and saw that Walker's CGM read 91. When I opened the text from Nicole it said "W-40! Drinking juice". For anyone unaware of what blood sugars mean: 91 mg/dL is a great target number. The kids' target is 80-180 mg/dL. 40 mg/dL is dangerously low. Diabetic seizing typically occurs when blood sugars drop below 40 mg/dL. We were right on the line, and all the adults knew it.
Thankfully, all the stars were in line for Walker on this day. Nicole was on her way in the room to check for snack just moments after Walker had started exhibiting the symptoms of her low. Her teacher noticed she was crying, something very unlike her. When her teacher asked Walker what was wrong she was saying that a boy in the class was teasing her. This boy was seated nowhere near Walker but instead his twin sister is her desk mate, and clearly she was confused and not making any sense in the telling of the story. Her teacher recognized the uncharacteristic behavior and told Nicole. Immediately Nicole checked her blood with the glucometer and saw the read of 40 mg/dL and gave her a juice box. When I received the text I ran over to her room and when I walked in I saw her feverishly devouring her snack. Her eyes were dilated and she looked both scared and manic. Both Nicole and her teacher also looked as though they had just seen a ghost. In the hours following, her blood sugar spiked into the 300s and then later in the afternoon began to level out again. This is typical for the liver dump that happens following a hypoglycemic episode. Later in the day I discovered she even bit her tongue in the frenzy of her eating. My poor girl was shaken, but I don't think fully aware of just how dangerous the whole situation was.
Not only was Walker's number 40, but she was also exhibiting the tell tale signs of a Moderate Hypoglycemic episode. There are three levels of hypoglycemia: Mild, Moderate, and Severe. Walker's blood sugar of 40 mg/dL put her in the "Severe" category.
Signs and Symptoms of Hypoglycemia
Mild: below 70 mg/dL
an urgent need to eat
nervousness and shakiness
perspiration
Moderate: below 55 mg/dL
dizziness
sleepiness
confusion
difficulty speaking
feeling anxious or weak
Severe: below 35-40 mg/dL
seizure or convulsion
loss of consciousness, coma
Depending on how many lows have occurred prior to an episode determines the severity of the symptoms and ultimately the outcome of the low. Sometimes a Mild low can result in seizing if the liver has been previously taxed. There is a small reserve of glucose that the liver is able to dump when blood sugars go low. In Walker's case, this saved her. She hadn't had any lows in the days prior to this moment so her liver was fully "stocked". Her liver was able to kick in and dump enough glucose to keep her from losing consciousness. But this is just to buy time. If the low isn't treated with an external sugar supply quickly then the low will persist to the point of death. To even write this makes me shake.
So how did this happen? I have no idea. It just happens. She wasn't dropping fast, her CGM just wasn't reading accurately. We were going along the assumption that it was reading correctly, since at 8am when I checked with blood prior to school starting it was pretty close to her actual BG. Her graph plots weren't bouncing around which is usually an indicator that the CGM is misreading, and her trend arrows weren't shooting in either direction. Nicole and I thought Walker was in a good place with her sugars. And this is where it gets tricky.
So much of diabetes care, especially as it pertains to children, is an art form. It's a look that just isn't their normal, or a behavior that is tweaked just a bit from their standard. We're part endocrinologist, part child psychologist, part exercise physiologist, and a whole lotta soothsayer. It certainly takes an army to keep my children safe, and I'm thankful for every single element that keeps it all together.
And on this night I certainly paid gratitude to her angels. Because there are days when there is no denying that fact that my children are watched over by many.
