A bolus of fear
The day to day worry involved with type 1 is overwhelming many days but there are certain situations that give an extra shot of fear that gets my adrenaline pumping: illness. I'm not being overly dramatic when I say that from about mid-October to the beginning of May I am a ball of nerves. Flu/cold/stomach bug season sets me on edge like no other time of the year. I'm in constant attack mode; meals are planned to be as nutritious as possible, eating out happens on the rare occasion (do you know how much of our seasonal germs are passed by simply eating at a restaurant?!), probiotics are treated like their own food group, elderberry syrup is constantly brewing on the stove, sleep is taken very seriously, and our hands are raw from incessant hand washing. At the most benign sounding sniffle or clearing of the throat the protocol goes into overdrive. As if my daily life wasn't already exhausting, this time of the year utterly wrecks me.
And why do I make myself mad with all this preventive care? Because even the smallest illness has the potential to be life threatening to my family. Any time there is a stress put on the body there are usually the development of ketones too. Ketones are deadly to T1Ds. Here's why:
Ketones are created in the body during times of illness, when blood sugar is high, and ultimately when fat is used as an energy source instead of glucose. Ketones are the chemical by-product of the breakdown of fat. Many of us have heard of or tried the Ketogenic diet. It's a high fat, moderate protein, low carb diet that forces the body to burn fat instead of carbohydrate. But this kind of ketosis is very different from the ketones that we fear in the diabetes world. Nutritional Ketosis is very different from Diabetic Ketoacidosis, so please don't confuse the two and think ketones are something healthy. What makes the ketones I'm discussing so dangerous for type 1s? The issue with ketones is that the only thing that flushes them from the body is insulin. Let me repeat that: the only way you can get rid of ketones in the body is with insulin and too many ketones in the blood is toxic. YOUR OWN BLOOD BECOMES POISON IF THE KETONE LEVEL IS TOO HIGH. For anyone with a functioning pancreas, no biggie. The body clears the ketones. For T1Ds, they need to up their insulin to deal with the ketones, or else they develop Diabetic Ketoacidosis (DKA) and may die.
So again, you may be saying, "why you so crazy Megan? Give them a little extra insulin and it will all be good.". It's not as if we can tell the insulin prior to bolusing "hey, just clear the ketones, but leave the glucose alone, kay?" Insulin is a work horse and takes no prisoners. Too little insulin, and you die. Too much insulin, and you die. It has a very specific job and it does it blindly. Most times, when we are sick, the stress the body is under raises blood sugar and creates ketones. If blood glucose levels are high, and there are ketones, the insulin brings both levels down. Great. But there are times when the body is sick and the blood sugars are low, like during times of vomiting. These are the times I cry with fear.
Imagine the dilemma: blood sugar is 98 mg/dL, ketone level is high. Too many ketones, your blood turns toxic and you die. Blood sugar too low, your cells are starved of oxygen and you die. The only way we can get ketones down is to introduce insulin into the system but by doing so the blood sugar will also drop. The only answer is to get the blood sugar up so that insulin can be administered. But the sick patient either can't eat, or refuses to eat. In times like these we have a few options. First, we try to stop the vomiting with an antiemetic like Zofran. I carry these with me in my first aid bag, right next to the bandaids and handiwipes. There's also the option of dosing tiny amounts of glucagon (that life saving red shot that forces the liver to dump glucose into the system). The other choice is a trip to the ER where they'll start an IV drip of dextrose + insulin to bring up the BG and bring down the ketone levels. Ketones are not something we take lightly in the type 1 world.
Last week, Ollie got sick. It started with a sore throat and congested nose, and within a couple hours morphed into fever and vomiting. At the first sign of fever I checked his ketones. You can do this with urine or more accurately with blood. With blood his levels were 0.3 mmol/L at 9am, glucose levels were 152 mg/dL, and fever was 100.1. (Ideally, ketone level should be 0.0, but under 1.0 mmol/L are considered low-moderate levels of ketones.) He vomited at 11am and I immediately checked his ketones again and they were 0.4 mmol/L, and I gave him a Zofran. In the past the Zofran has allowed us to give him some juice. With any GI issue we try to keep the kids "a little sweet", and get their blood sugar above 180 which allows us some wiggle room in case they need insulin because of ketones. This time the Zofran didn't work as well and Ollie threw up again about an hour later. I called the on-call nurse and told her the situation, telling her his ketones were still at the 0.4 mmol/L range and that his bg was about 180 mg/dL. She was comfortable with those values and told me to call with any changes. At that time Ollie fell asleep and when he awoke 3 hours later I checked his numbers. I had been watching his CGM graph climb while he slept, topping out at around 250 mg/dL. I was shocked, however, to test his ketones and find them to be 3.7 mmol/L! I had him wash his hands and test again because I was sure there must be some mistake. I had never seen a reading that high on the meter! He tested again, only this time it read 3.8. I immediately called the nurse. From her tone, and what I knew of ketone levels, we had a small window to work with to get these ketones down before we had to leave for the ER. I had to give him a shot of insulin. With high ketones you need to bolus insulin via syringe since pump sites can sometimes get plugged or congested and we can't always be sure the insulin got into the system. This was the first time Ollie has had to have a shot of insulin in almost 2 years and he wasn't happy. Once the unit of insulin had been given I had to see if he could keep any food down. We started with a few saltines and after a 1/2 hour felt confident we could bolus some more insulin to get the ketone levels down. I changed his pump site, adjusted his continuous basal drip to dose more insulin per hour than normal, bolused another dose of insulin for the crackers, and waited a few minutes longer before testing his ketones again. Forty-five minutes after the first shot of insulin Ollie's ketones had dropped to 2.4 mmol/L. I called the nurse back and she sounded as relieved as I felt. The ketones were coming down and we had dodged a trip to the ER. Ollie was able to drink a little juice and we were able to continue dosing insulin and get his levels down. At bed time he was down to 1.1, and at 9pm he was down to 0.4 mmol/L. The next morning he felt a lot better but continued to have a fever. His ketones stayed in check and we avoided the hospital.
As if having a virus isn't painful enough, ketones make the body feel doubly crummy. Nausea, vomiting, aches, dehydration, confusion, and fatigue are all symptoms of DKA. It's hard to separate the DKA symptoms from the other illness. And it makes recovering from illness that much more difficult.
So that's why, when you see me from October to May, I may look a little more crazed than normal. (Ha! Normal, that made me laugh!). So before you send your "kind of under the weather" kid to school, or you yourself make a grocery store run while just getting over the flu, think about all those immunocompromised members of your community. Many of them look totally healthy from the outside but are working extra hard to ward off your nuisance bugs. No man is an island.
