Friday, June 09, 2006

Once More Into the Woods

As the school year comes to a close, Joseph and all of his classmates prepare for their annual overnight field trip to the School Forest. Now, although Joseph and Ryan went last year and had a blast, I'm once again feeling anxious about this outing. There's just so many damn variables-- out-of-the-ordinary activities; foods with a mystery number of carbs; unexpected, and in many cases, unsupervised trips into the woods . . .

Add to these things the fact that Ryan can't do the overnight this year (he's got to work like a dog all week), and that Joseph's class will be joined by four other classes-- meaning many, many more kids than last time -- well, my stomach is in more than a few knots.

Oh and yes, I'm one of the chaperones (along with my trusty three-year-old sidekick, of course).

Did I mention we'll be sleeping in tents?

And that I've not ever actually pitched a tent?

Well, not until Sunday, that is-- when for a trial run, Joseph and I put up the one we'd purchased that day.

This would be the tent we went out and bought because the one that our neighbor was willing to loan us came with no instructions and was (as he put it) "a bit of a challenge to put together."

Uh huh.

After about 45 minutes we had the thing in place, and I must say it looked quite nice-- more like a small condo than the six-person tent described on the packaging.

Of course, Joseph insisted we sleep in our new tent that very night because "Mom, it's in the backyard and it'll be fun!"

And you know what?

It was.

It also put me right back to the one and only other time I'd slept in a tent-- Joseph had figured large then as well.

Two days after our overnight in the backyard, Joseph leaves for the forest by school bus with the rest of his classmates, while I load the car with our gear-- including the two large bags full of our new tent (no matter how much folding and re-folding, there was no way I could get the darn thing and all of its components back into its original small duffle).

When Evan and I arrive, there's no one at the camp site. However, under a nearby covered pavilion there are at least a hundred rolled up sleeping bags, duffles and backpacks strewn all over and under a dozen picnic tables.

The kids are definitely here. They're just all out in the woods.

At this point, I remember that there was talk of starting the morning with a two-hour nature walk. And now I begin to worry.

What if it's like last year's walk?

I try to keep my mind off what might be happening out there by playing catch with Evan-- missing the ball repeatedly as my eyes wander to the trees surrounding the large clearing where we'll be pitching our tents. We run around, playing chase all over the very sunny, very hot, open field.

Eventually, I convince Evan to walk a little way into the woods, but she quickly gets scared and runs back to the clearing.

Man, I wish I could just hear them.

Finally, after over an hour, kids begin spilling out of the woods-- just a few at first, then dozens of them. Among them are Joseph and his buddy, Sam. They're messin' around, laughing hysterically at something only the two of them seem to understand. I feel a tremendous wave of relief, smiling as I walk toward the two boys. But as I get closer I see right away that Joseph isn't just laughing at some inside joke.

There it is-- that big goofy grin, the extreme silliness.

And as I listen to his banter-- the slurred speech.

He doesn't seem to hear me when I ask him to check his sugar. He just continues to run around -- almost staggering, really -- with his friend.

I have to chase him down, and get him to look at me before he even realizes I'm there.

"Oh Mom, we're just havin' some fun," he says, swaying a bit and sounding drunk.

Oh God.

"Honey," I say, as calmly as I can. "You seem low. Please let's just check your sugar."

"But Mom, I felt low on the walk and took a few glucose tabs. I'm fine."

"How long ago was that?"

He looks at Sam, and they both agree-- about twenty minutes earlier.

We check his sugar-- he's 53.

And suddenly he's acting cold sober, sitting on the ground and eating three more glucose tabs. We wait 15 minutes and check again.

He's 52.

Christ-- why didn't I get here before they went out in the woods?

I fight back tears as Joseph takes three more tabs.

Fifteen minutes more and he's 75.

And from that moment on -- after a huge lunch; climbing on rocks with his buddies; playing soccer; two large slices of pepperoni pizza for dinner (several teachers "delivered" the pizza to the camp); snacks that included an indeterminate amount of "puppy chow" (Chex covered in peanut butter, chocolate, and powdered sugar), chips, cheese curls; crazy skits and songs by the campfire; numerous card games; and, my God, S'mores... yes, after an extraordinary amount of fun --

Joseph's blood sugar never went over 150 or under 73.

Even overnight.

And believe me, I checked.

Several. Times.

While the sidekick slept.


Scott K. Johnson said...

After the scary start, it sounded like things went great.

gah. I've typed and re-typed stuff over and over again, looking for some super great and reassuring advice from a "seasoned pro", but just can't get it right.

Maybe when he's out and about like that, you can come up with some agreement to eat more glucose tablets than he typically would?

I just turn to mush anytime you post pictures of your little girl. I think because she reminds me of my own daughter.

Felix Kasza said...

Dear Sandra,

wouldn't the tears better be held in reserve for when Joseph experiences a truly unpleasant hypo? 53 mg/dl is no reason to panic.

Aside from that, perhaps Joseph would be interested in BGAT? Activity often masks the more immediate hypo symptoms caused by adrenaline, and at least I experience neurological symptoms earlier than the "regular" ones. That makes BGAT very useful for me.

Scott's suggestion of treating the anticipated trend instead of the current low is a good one. If it could be coupled with a deeply ingrained "test NOW" reflex, how pleasant that would be! What I am trying to say is that the only mistake I can see is the absence of a test, unless you skipped that detail in the narration -- "I felt low ...".

Feeling low should cause an immediate grab for the test kit, and yes, one can train both the grab and the proper treatment to happen at BG levels that are surprisingly low. (I am reasonably functional down to 40, but can self-treat to the low 20s.) And while there are no "bad numbers", the _absence_ of numbers is bad, should be clearly defined as bad, and carry consequences.


Sandra Miller said...


Thanks. Asking Joseph to take more glucose than usual in this kind of situation is a really good suggestion.


You're definitely right about the tears-- though they were less a result of the 53 (certainly not the first time we've seen that number), and far more the result of the long wait for him to come out of the woods, the fact that he'd already taken three glucose tabs (thus he'd likely been lower than 53), and just the thought of what might have happened had I not been there...

Now this might be a dumb question, but what is BGAT?

And finally-- good pick up! Indeed there was no test in the woods when Joseph first felt the low.

With all the kids around, and it being so close to the end of the hike, he thought he could just take care of it with glucose tabs. He certainly was right about having been low. But without the number, he had no idea how low he'd gotten or how fast he was falling... Nor did he stop and wait for the glucose to take effect (probably because this would have forced the whole group to stop as they couldn't just leave him 10-15 minutes behind without a guide).

Bottom line, I let him know that I understand how he felt, but not testing, and especially not waiting for his bg to come up before continuing (which again would require a test to confirm) is not acceptable-- under any circumstances.

Angie said...

I feel your pain. I hate the thought of Cassie going off on a trip and my not being there. Even thouigh the teachers and school nurse have dealt with her for 4 years they still don't treat her BG levels like I would. They often over feed her for lows and she goes sky high, or they let her give insulin more than once an hour for highs and she goes too low. And she is 14. I couldn't imagine being in this situation. I would have been frantic myself and I know that I would have embarressed her horribly. I deal with your fears daily. Even at 14 she still doesnt' quite get it. I hope that in years to come she will become more independant and take better care of herself. Cassie hates glucose tablets and yes she refuses to eat them. We use smarties and OJ, we also use fruit snacks, like fruit gushers. One pack has about 19 carbs, but it usually takes 2 packs to bring her up to normal. The 15 carbs 15 mintues doesn't work for cass, 30 carbs 15 minutes seems to be the right combo for her. Every diabetic is different. Congrats on surviving the field trip and I bet he loved getting to eat all those forbidden foods and not having the forbidden side effects.

Scott K. Johnson said...

I believe that felix is referring to Blood Glucose Awareness Training.

This workshop is at Joslin's, but I would imagine there are others around too.

Very good suggestion felix - I hadn't even thought about that. I feel pretty in tune with my BG's, at least when lows are concerned, but a younger diabetic may not be tuned in quite so tight.

Sandra, this might be a very worthwhile thing to look into - it would serve Joseph very well for the rest of his life.

And I don't think the tears were really from the low, but rather your feeling of vulnerability because he was off on his own. You didn't cry because of the low, but rather that you weren't there to catch it right away.

Very scary for a parent of a diabetic child - I can only imagine. My kids are young enough where they are still very close, and even with no additional health concerns I am very scared when expanding their "roaming territory". Something that all parents go through I imagine, but the extra worry due to blood sugar management adds a bit more concern to it for you.

I think that as Joseph's ability to sense when things are out of the norm, or take pro-active action (like that time when he went to the movies), you will start feeling more confident of his own abilities to manage, and that will help you be more comfortable. That BGAT may really be helpful.

In fact, I might like to investigate options in my area too. I hadn't even thought about that until felix mentioned it - but I have heard of it somewhere before.

Tiffany said...

Sandra, I really think you should gather each and every post on your blog and turn it into a book. You can make me laugh, and wince, and smile, and want to cry -- all in one paragraph. Each and every time.

I'm not so far from my childhood that I don't remember having a rocking fun time that was interrupted by a low. My mom and healthcare team trained me to test for lows, to recognize lows, to treat lows, etc. etc. Did I follow through every time? Nope. It wasn't me that interrupted late-night games of chase with all the kids on our street; it was my little sister who would run to mom yelling "Tiff needs a juice box!" And my mom would race out of the house, carton in hand, looking much the same as you did in this situation, I'd imagine. Looking back on it as an adult, I would guess that she fought tears every single time something like that happened.

It was her prerogative as my mother. And it's your prerogative as Joseph's mother.

I too think that's Scott's suggestion is gold. Whether Joseph tests or not, at least you can be assurred that an excess doseage of glucose will avert any immediate disasters.

In addition, you might think about teaching him how to suspend his pump when he is low, or at least set a temporary (lower) basal rate as a stop-gap. This trick has served me very well over the years I've been pumping.

Sounds like it was a great time! Do I get to come next year? ;)

type1emt said...

Sounds frightening, I'm glad you did
"catch it" before it got worse.

Have the benifits of BGAT been tested in a pediatric endocrine setting? (kids can notice certain indicators of being low, others they can't) And I've done stupid things before(as pertaining to hypoglycemia), being low makes it quite hard to think rationally.(Even when you've had BGAT training)
At least Joseph recognized he was having a low, and ate some glucose tabs.
Don't know if this would work..but would Joseph ever tell a teacher/assistant that he's having a low? I can understand about not wanting to hold up the group, but surely they could make sure he tested/ate enough to get out of the low.(not making a big deal out of it)
Glad that the rest of it went ok.

Felix Kasza said...

Hello again, Sandra --

apologies for my being too lazy to spell out Blood Glucose Awareness Training, and many kudoi to Scott for supplying what was missing!

Tiffany mentioned suspending the pump or setting a lower temp basal -- an excellent idea for hikes that are expected to go on for quite a while yet. In this instance, unless I misunderstood the timing of Joseph's hypo, the usual delay in a basal change's taking effect would have made that intervention too late. Also, one needs to be careful of a rebound high.

As a general rule, I never ever suspend. A temp basal has the major advantage that it ends on its own should I be stupid enough to forget that my pump is not delivering insulin. :-) Also, and I think Tiffany would agree, a reduced basal is _not_ a treatment for a low. It is, at best, a supporting measure when one suspects an ongoing downwards trend -- exertion, misjudged insulin dose, things like that.

One other thing I forgot in my earlier comment -- "all's well that ends well." A platitude, to be sure, but a perfect fit here.


julia said...

Suspending the pump and/or doing a temp basal is a great suggestion in this situation.

Also, you might want to look into high protein/high fibre combo snacks when he's going to be super active like that. It'll sustain his bg better than just juice or tabs - although keep those around, they're good in emergencies.

Could you get him an alarming watch and set it for every 30 minutes or half hour when he's off doing something like this? I know I set alarms on O's pump, but she doesn't always hear them or pay attention to them. A watch alarm (there's one out there that has about 10 alarms on it - I think it's a medical one) would draw attention to him and get someone else to give him the nudge to check even if he wasn't paying attention.

It sucks that our kids have to do this, but they do. O is really bad about remembering to check when she's involved in things and it drives me crazy. I'm trying to train her to do it, but it's an uphill battle.

Tiffany said...

Actually, Felix, Tiffany is going to have to disagree with you on this one.

I have, many times, treated a low simply by suspending my pump or temping down to a <10% basal. Without the assistance of any form of oral glucose or injected epinephrine. And during periods of physical activity.

But you make a very good point about active insulin affecting the natural processes of the body in normalizing BG levels. The trick to treating a low by temping or suspending the pump is dependent upon the active insulin as well as sensitivity level and counterregulatory response, to name a few.

All we can do, in cases like this, is evaluate every tool available to us and then find out what works best.

Sandra Miller said...

Awesome suggestions.

Thanks again for sharing.

(And Tiffany-- if you're game, Joseph's teachers are always looking for more chaperones ;)