Sorry for the dramatic headline, but I see posts like that every single day. Most often it is relating to an alert from a dog. See, this happened to me too, just this past weekend. 20150815-DSCF1638

We were at a birthday party for our 11 year old cousin. Lots of kids, lots of games, lots of fun. We were in an air conditioned party room, but there was a park outside where most of the games were played. The temperature was in the 100’s on that day. We had Major with us. When at events like this, we put him under a table out of harms way. He is our public access rock star and excels in these types of scenarios. He is black, and if you are in a place not normally associated with having animals, he could potentially create a tripping hazard.

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Major showing “under”

Now Major is so good at staying and “under” that if he DOES start to stir or break his place, I know instantly that we have a blood sugar issue to deal with. The party was at lunch time, so we knew there would be food involved. But one of the first events was a watermelon eating contest. To win, you had to eat the watermelon fast and not leave any meat on the rind. We are always big advocates of letting Stella participate in as much normal stuff as possible, and she loves watermelon. I looked at the slices and bloused appropriately. But there was no way to deal with the speed in which the BS would rise due to how fast the kids ate the watermelon.

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Shortly after that we went back inside and prepared for lunch. The hosts bbq’d, so we had tasty burgers, hot dogs, and fruit and veggies.

As I was sitting down at the table Major alerted. I tried my best to capture it in action, but missed focus on the last image. Here is what happens. First he crawls out from under the table. (at that point I normally grab the meter, here I grabbed my camera 🙂  )

He sits in front of me and gives me the “death stare”. We call it that because it is very intense, very focused. And then 2 paws on me. (no picture of that). That is the alert. 2 paws on me. After that initial alert I can ask him to show me what it is. He will bow for a low (going as “low” as he can) or he will wave one paw (a wave to say “hi”).

Crawling out from "under"

Crawling out from “under”

The "Death Stare"

The “Death Stare”

the one paw wave to say "hi"

the one paw wave to say “hi”

We tested Stella and she was 172 and rising. I knew it would happen.And I am always amazed that Major catches these while in the midst of what for a dog must be a very stressful situation.

No long after we had lunch. Burgers, a bun, fruit, and a pending birthday cake. Lots of carbs, and with a delicious homemade cake, no real way to know the carbs, just giving it our best guesstimate. After 5 years, I’ve gotten pretty good at sagging the number of carbs in food. It’s my inner Rainman.

 

Sidebar: I’ve been reading a lot about dogs that alert to incremental shifts in blood sugar. That these dogs are trained to alert to shifts. And those shifts could actually be “in range”, like a drop from 150 to 120. Or a rise from 100 to 145. And these dogs are being rewarded, and the type 1 is being treated. See, here’s the thing. I can train Stella at 1pm and she can be 120. I can test her again 1:10pm and she can 142. And I can test her again at 1:30pm and she can be 100. Without me doing a thing. Now if Major alerted to all of those shifts, then I am nothing more than a human treat dispenser and I’m being played by my dog. The truth is that the meter and test strips have an FDA ALLOWABLE +/- of 20%. That means a reading of 180 could actually be 144 to 216. So in my example above, she could have been a rocksteady 120 the whole time. More on meter accuracy here: BG Meter Accuracy

As such, we generally only reward for out of range, verified testing. If one of our dad’s alerts to us and Stella is in range, we tell them we will “watch” and retest in 10 minutes. More often than not, they have picked up on a big swing, and she is going out of range. But again, we don’t reward until we verify that the BG is out of range. There may be times where we may have some knowledge that will help us verify what the dog is smelling, and on occasion we may treat the BS and reward the dog, but that is an exception, not the rule.

:end rant:

Okay, so back to lunch. Lots of carbs, already starting a little high from the Watermelon, but she already has IOB (insulin on board) to cover those carbs, so I only bolus for the carbs she is eating. The bun, fruit, and a slice of cake. It looked to be about 100 carbs. Her lunch time ratio currently is 6 carbs to 1 unit of insulin, which would have been almost 17 units of insulin, but based on the heat and knowing there were still some activities coming up I cut that to 12.5. Just another decision that constantly needs to be made on the fly with known circumstances and pieces of information about what comes next when administering a medicine that she needs to maintain life, but could also kill her if mistakes are made. No pressure… 😉  Insulin is NOT a cure, merely life support.

Lunch was had and enjoyed. 20 minutes later the kids were off to the park to go play some more games and on the playground. I tested her and she was 213. No surprise there. Again, it was 100 degrees. About 30 minutes later I get this:

Major Low Alert

Major Low Alert

Major alerted to a low. I tested Stella and sure enough, she was 72 and heading down. Good boy Major. In all this heat, a public park with lots of dogs, lots of kids, a BBQ, and who knows what else your amazing nose was picking up, you could still sort that all out and know your girl had an issue.

As I tested her I also checked to see how much IOB she had. Our Animas Ping pump and connected meter keeps this number based on calculations we input into the device. She still had about 8 units of IOB. This is normally the part where you see someone say “OMG MY DOG JUST SAVED MY VHILDS LIFE! HE ALERTED AND SHE HAD 8 UNITS OF IOB!!! THAT”S ENOUGH TO KILL EVERYONE IN A SMALL VILLAGE!!!”

And, while truth be told, if we just injected her with 8 units of insulin for no reason, then yes. So, next time you see that headline, please ask this very important next question: “Why was that insulin there?” “Were you absent minded?” “Were you purposely trying to kill your child?”. The answer is no. The child had IOB because they had a meal or a snack or a correction. Now that correction could have been based on bad information. Like dirty hands that gave a false high reading. But the truth is that IOB was there because someone purposely put it there. (yes, there are a small number of incidents where a child has accidentally administered insulin. In which case, BRAVO! Amazing Dog!) But the reality is the insulin is working on food in the system or correcting a high.

In our instance, I had some facts. One is that I knew she had eaten about 110-120 carbs in the past hour. (Lunch, cake, watermelon). I also knew that I bloused conservatively based on the heat and anticipated activity that was coming up. The cake was a guess, but worst case, I wasn’t off by more than I bolused for. So what now?

I treated conservatively. I gave her a small sip of Gatorade. When out and about it is our go-to for corrections. It comes in all sorts of sizes, easy to carry in a purse or backpack, lots of flavors, can be found at any store, and we don’t see the crazy spikes like we do with fruit juice or apple juice.

Major alerting to Stella while we were testing and she drank her Gatorade

Major alerting to Stella while we were testing and she drank her Gatorade

I checked her again 10 minutes later. She was 75. 1 more small sip. Why only small sips, so conservatively? Because I knew she had ALL that food in her system, and this low was temporary. If I ever reacted and gave her the whole bottle, her BS would have sky rocketed and I’d have a much harder time dealing with the stubborn high. I knew that as soon as we stopped and got into the car, her system would go right back to working the way it was supposed to. And sure enough,  when we were finished at the party and heading home (about an hour in the car) her BS settled into a nice 100-110 the whole way home. Much better than dealing with a 200 or up while sitting in the car. (or for the rest of the afternoon)

And that is another piece that often is left out of the “SHE HAD 8 UNITS OF IOB AND COULD HAVE DIED!!!” post. No one ever tells you what the child was an hour later after they administered fruit juice, candy, cake frosting, etc. They never tell you that for the next 8 hours they couldn’t get them under 300, they had a nasty headache, felt crummy, and had an awful day.

Stella says "thank you Major!"

Stella says “thank you Major!”

Hoping that this helps people understand a little more about IOB, rewarding dogs based on BS movement, and just how amazing a well trained dog can be.

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Team Blackdogsrule

 

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12 Comments

  1. We’ve never used Gatorade to treat a low but after reading this post, We are going to give it a try.
    Nice explanation of IOB. Your blog should be required reading for any family considering a DAD. Thanks Frank!

    • Hey Jenn, would love to hear how Gatorade works for you. While fruit juice may work faster, it creates a spike that we don’t see with the same amount of Gatorade. (juiceboxes are still our goto overnight correction, can’t beat the straws 🙂 ) And the bottles have ribs on them, so I can tell Stella to drink to the first rib, second rib, middle, etc. And you can cap it up and put it back in your pack

  2. Frank have you ever thought about being a teacher. Even as a nurse I learn a lot from you. Medical knowledge has come a long way since my daughter was diagnosed, we didn’t count carbs, we did food exchange.

  3. I have had type 1 for 44 years and learned something new today. Thanks for the great information!

  4. I love this, I too have read so many time about this same thing. I often wonder being a Type 1 Mom to a teenager how much info they are leaving out.
    Thanks for such a great blog.

  5. Thank you for sharing this. While I have no one in my family that has diabetes I do have a number of friends or my kids have friends who do. I like to learn as much as possible. I am a dog trainer and trying to lean about service dogs and how I can help people who need work with their service dogs. The information I get from things like this is invaluable to me. Thank you. Also I would like to say I love your tag, black dogs rule! I have 2 black dogs myself 🙂

  6. I am liking the gatorade suggestion. Emory just got braces on. His go to for a low was always an airhead. This sounds like a good alternative. I am noticing Stella has a bandage around her arm. What is that for? I am asking because we are having HORRIBLE problems getting EMory’s CGM to stay on this summer. FIrst day wearing it, two hours in the pool and the dang thing is already falling off. Suggestions?

    • That is EXACTLY what this is for. It’s called vetrap. It’s like an ace bandage, but it sticks to itself and is waterproof, you cut it to length. We use it to cover her CGM and we get 14-18 days of use out of each site. It is real cheap on amazon.

      • Do you always put it on her arm? Emory has pt it n his arm but he also wears the Cgm of his stomach and lower back. I will get this and try it though. Today we are trying tegaderm. Each day we try something different. I read your site and I am in awe with all you know 5 years in and I still feel green when I read your posts!

        • We used to put it on her stomach and lower back, but we never got it to last more than a week. On her arm we easily get 2 weeks. she also prefers it there

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