Under the Influence of Insulin

Today’s paper carries an article about the arrest of a diabetic man who caused a horrific car accident while in the throes of hypoglycemia. He is charged with “driving under the influence of insulin.” No kidding. The prosecution alleges that he injected himself with too much insulin about 2 hours before the accident. What is unstated is that the driver should have known better.

Two young people were killed in this wreck and seven other people were injured, including the diabetic driver. I remember the wreck – it was quite a headline-maker for several days. A day or so after it happened, the driver’s diabetes was implicated. I remember being glad that it wasn’t some stupid drunk and feeling sorry for the driver. I never thought him to be negligent. And this was before Isabella was diagnosed and before I learned so much about the literal ups and downs of diabetes.

Now, reading the article about his arrest and the intention to prosecute him for manslaughter, I am appalled. How ignorant. But I’m also realizing just how little people who don’t live with diabetes know about the disease – ironic, since seven months ago I was right there with them.

I can rapidly catalog what I “knew” before Isabella introduced me to diabetes:

Hypoglycemia: There was a girl in my 7th grade homeroom who was diabetic. I was jealous because she had standing permission to eat a snack whenever she needed it.
Fake sugar: My grandfather became diabetic late in his life. He had to eat nasty sugar-free candy. My mother made two pumpkin pies every Thanksgiving: one regular and one made with sugar substitute. I never tried Grandpa’s pie.
Injections (1): Beth, my step-grandma, injected his insulin. Later, I injected her with procrit. The experience of giving injections to a human made poking a syringe into my cat a breeze.
Injections (2): I once happened upon a co-worked with a syringe. To my questioning look, he replied “I’m diabetic.” I can’t clearly recall if he had been injecting his arm or his torso. If it was his arm … well, maybe he ain’t diabetic after all.
Pumps: I used to swim with a gal who is diabetic. She had a pump. We never really discussed her diabetes, except that she once told me she had trouble keeping it under control.
Possible eye troubles: Nina Courtlandt, a character on All My Children, was diabetic. She was constantly threatened with blindness, collapsing at inopportune moments, and the like. I’d guess that she wasn’t too well controlled, either.
Poor circulation & wound healing: The woman who had this job before me is diabetic (Some would say I stole her job. Let’s not go into that now.) She is morbidly obese and has the gnarliest-looking feet I’ve ever seen. Several years ago she needed surgery for a broken ankle. When the surgical wound wouldn’t heal, her foot was very nearly amputated.

And that’s about it. A patchwork of exposures and experiences that add up to not a whole lot. I’ll bet that my catalog is very similar to what the average guy knows – and that the average guy could easily believe that the diabetic driver involved in that crash “should have known better.”

It’s only because of my cat that I realize the true trickiness of diabetes. Every day I’m glad when Isabella greets me at the door, because I know that there’s always a risk of finding her hypoglycemic, or worse. Her blood glucose is up and down. And I know from reading the blogs of human diabetics that people contend with the same ups and downs and that even experienced diabetics are caught off guard.

I hope someone in the District Attorney’s office comes to their senses and drops this case before it goes to trial. And I hope that driver fights the charges with everything he’s got.

Here we go again...

She's doing it again.

My diabetic cat is giving me high blood glucose numbers. As in nearly 400.

After several weeks of staying in the 200s or lower, I had the audacity to think that maybe I'd found the right dose: 1.7 units BID. Not 1.6 units. Not 1.8 units. But 1.7 units.

Now those dreaded high numbers are showing up again. High numbers can mean she's not getting enough insulin. Or high numbers can mean that she's getting too munch insulin. With Isabella, at this dose, I'm guessing that her body has decided it's too much. 1.7 is three tiny drops away from 2.0 units. The only thing that's been consistent about Isabella's diabetes these past months is that 2.0 units is too much. So, when I start getting close to 2 units, I pay very close attention - to the cat and to the numbers.

Sigh. I'll give her a half dose this evening. I'll bet that her blood glucose drops like a rock. And I'll bet that if I stick with the smaller dose for any length of time, her numbers will start creeping up and her dose will start creeping up until I'm back to 1.7 units. Where we'll stay until her body decides it's too much.

Around and around and around we go...

No Tresspassing?

It was what, two weeks ago, that I blogged about how I get blood from Isabella for her twice-a-day glucose tests?

Well, toss all that out the window, because things have changed. We have a new system now and it’s a lovely thing indeed.

A few weeks ago I started wondering why the folks on the Feline Diabetes Message Board always instruct newbies to poke between the vein and the outer rim of the cat’s ear. It makes sense to avoid the vein (pricking it releases a gusher of blood that’s nearly unstoppable. One shake of the cat’s head … and you’ll be wiping blood from the walls and every other conceivable surface), but why restrict the poke-able area to that tiny 1/8th inch margin? What about the rest of the ear? That whole, juicy part in the middle?

I’ve wielded the lancet freehand this whole time because I can’t accurately aim the lancet-launcher-pen thing at that teeny little margin. And, as I described before, Isabella finds my poking technique to be harsh. So you can understand why I was eyeing the middle of Isabella’s ears like a land-owner might survey an adjoining off-limits property.

Finally, I just asked the question. I posted a message to the Board asking why. Why not use the whole ear? Guess what: no one had an explanation. Not one single response had a reason that was good enough to convince me that it was anything other than “that’s just the way we do it.”

It was as if fences were torn down and the No Trespassing signs burned. I marched into that un-poked territory with great confidence – and – the lancet-launcher thing. Now that I didn’t have to aim so bloody carefully (oooo, that’s a bad pun!), I could use the launcher that Isabella so clearly preferred. No more shrieks from the cat. Blood drops are easily obtained and the whole process now takes about a minute.

I don’t have to wrap her in a blanket. I just plop her on the couch and she sits.

For freehand I was using a fine-tip lancet, the smallest I could find. With the launcher, I moved up to a fatter tip, but Isabella’s discomfort is still dramatically reduced. She flinches a little, but doesn’t move or run away. The whole change is so cool. I’m glad I broke tradition and tore downs those fences.

Only one thing hasn’t changed: I still wear leather gloves. It is, after all, Isabella, she-devil of diabetic cats.

Judge thyself not…

Sometimes, it’s really hard to avoid taking Isabella’s blood glucose numbers personally. Really, really hard.

As I’ve blogged before, when Isabella was first diagnosed as diabetic I naively assumed that it would be a simple matter of insulin in, blood sugar down. Higher number, more insulin; lower number, less insulin.

But it’s not like that at all. Well, it is sort of like that – insulin does cause blood sugar to go down...most of the time. And higher numbers do warrant more insulin...except when they signal a need for less insulin. But never -- never -- can I absolutely rely upon a linear dose response. I can’t plug 1.7 units of PZI into my cat and know that it will knock her blood sugar down 150 points, with the nadir coming at 8 hours after the dose. “Predictable” and “diabetes” have nothing in common.

It’s taken me a while to truly understand that though. Isabella got her first insulin seven months ago. The very day of her diagnosis, I discovered the Feline Diabetes Message Board, a marvelous community of diabetic cat owners. I learned more from the folks on the board than I ever will from the vet. These people are living it, day after day. There’s always someone online who knows what you’re going through. It’s a fantastic place of shared knowledge and camaraderie.

It’s also a place where the success stories are front and center. Tales of cats needing insulin for only a couple weeks before becoming diet controlled abound. It’s a very encouraging thing for the newbies to talk to folks whose cats are happily eating low carb and off insulin for months or years. It’s easy to assume that your cat will be the same. Then as the weeks slog by and the glucometer keeps spitting out ugly numbers like 372, it’s even easier to assume that you are a failure.

I have hit the wall of failure many, many times in my travels in the land of feline diabetes. I have seen those ugly numbers on the meter and crumpled into a little pile of self-loathing. For months I was certain that each change in Isabella’s dose would be the magic change. Her numbers would drop! She would be regulated! Or, maybe, she would go off insulin altogether!

But test after test would reveal that no, her numbers are still all over the map, she’s not regulated and she probably never will be regulated. I was a mess. Every high reading was another black mark. I would enter those horrid numbers into a spreadsheet and plot the graph of failure. I was ashamed to go to the vet.

Two things have helped me to gradually let go of that shame. The first was the vet, who pointed out more than once that Isabella really looks good. Her weight is stable. Her fur is silky and shiny. She’s eating a normal amount, peeing a normal amount, and is not sucking water from the bottom of the bathtub. “Look at the whole cat, not just the numbers.” This is very, very good advice.

The second was that I realized that among all the folks on the message board who have fabulous success treating their cats, there are many more who quietly plod along, day after day, struggling with stubborn highs, freak lows, and infuriating variability, just like I do. My cat is not the only one. I am not the only one. I am not a failure. We are all doing the best we can.

Now, when I see a good number (which, for me, is anything in the 100s) I’m happy that Isabella is probably feeling pretty good that day. When she’s in the 300s, I give her extra chin scratches and let her sleep. A number is just a number. Not a judgment.

Insulin guess-work

Isabella coughed up another unexpectedly low number yesterday afternoon: 133. Last week when she gave me a number too low to shoot, I waited until her blood glucose rose higher then popped in about 1/3 her usual dose. The next morning her glucose was in the mid-300s.

So last night I tried a different approach. when I saw the 133 on the meter, I decided just to skip her evening dose altogether. (Though I did go through the faux-poke routine with a capped syringe, in case the idea of insulin has some effect.)

This morning: mid-300s.

Okee doke then. I'll never figure this out.

Isabella, meanwhile, is happy as a clam. She seems not to care if her blood sugar is in the low-100s or 300s. It's only those double digits that make her squirrelly, and that's what I'm trying to avoid by not shooting her when she's at, say, 133.

How to get blood from a cat

As I’ve said before, a major element of managing Isabella’s diabetes is testing her blood sugar before each insulin injection. If you’re familiar with feline diabetes, you may have seen this video, where Mark demonstrates a blood test on his cat Buddy. Pretty straightforward, right?

Sure, for Mark and his robo-cat.*

Around here, the twice-a-day blood tests have a slightly different look. Oh, the basics are the same: I use a glucometer, a lancet, and there is definitely a cat involved. But I have to add two other tools for my own safety: a big blanket and leather gloves.

Isabella, you see, isn’t too fond of the tests and she shows her displeasure with her teeth. Her sharp, flesh-tearing teeth.

The routine goes something like this:

I feed the cats (I learned pretty quick not to try the blood-letting on a hungry cat) and while they eat, I prepare the testing supplies. I get a test strip and put it in the glucometer almost far enough to turn it on, uncap a lancet, and lay the blanket open at the end of the couch. When the cats are done eating, Isabella comes to me expectantly. That’s when I get out the treats (bonita flakes) and the rice sock, which I warm in the microwave for 15 seconds, as I put on a pair of leather gloves with the finger tips cut..

I carry the treats & sock to the couch, with the cat trotting happily behind. I pick up Isabella and plop her (purring!) onto the blanket, where she sits as I wrap her like a little fur-filled burrito, leaving only her head showing. (Note: her head is where her teeth are. Hence, the gloves.)

Now the fun begins. Using the warmed rice-filled sock, I rub one of her ears to get the blood flowing, while also giving Isabella lots of chin and cheek scratches. She purrs, eyes closed. Drop the sock, grab the lancet, poke the ear. Isabella screeches as if I’ve sliced her entire ear off with a dull blade, and jumps – often getting partly free from the blanket – and bites whatever part of my hand she can get hold of. (She could get out of the wrapper at any time with minimal effort. It only sorta restrains her.)

I continue rubbing her ear, from bottom to top, hoping to bring a drop of blood to the tiny hole I’ve just made. Isabella growls. With luck, a big enough drop forms and I push the test strip fully into the glucometer, get the blood and a satisfying beep from the meter. If not, another poke, another screech and more rubbing. At the end, there are always bonita flakes for Isabella (and for Casey, who learned that if he hung around while his sister was abused, he would get rewarded. As if watching her abuse wasn’t treat enough.)

Most of the time, the process works. Sometimes after I wrap her, Isabella just calmly walks out of her restraint. Sometimes, her ear just won’t bleed. Sometimes – like last night – she’s just so feisty and vicious AND her ear so bloodless, that the whole process is a waste. But the majority of the time the deed gets done.

I don’t know why other folks can poke their cat and the cat doesn’t flinch. Maybe I’m just clumsy and heavy-handed. I’ve tried the lancet-launching pen and Isabella doesn’t feel a thing. But I find it hard to aim and hard to get a drop of blood, which leads to longer restraint, many more pokes, and, overall, a more stressful effort. So I’ll stick with my routine, as I’m sure, others find what works best for them.

After all, there are many ways to get blood from a cat.




*No offense Mark – your video is fantastic and I’m jealous of your well-behaved cat.

One Twenty Seven

Today after work, I tested Isabella’s blood sugar, like I always do. For the last two months her glucose has been stubbornly in the 300s, maybe with an occasional dip into the high 200s. Today: 127

Now, I don’t know why today it’s 127. But it’s because of these random low numbers that I keep subjecting my cat to the twice-daily blood-letting. 127 means no insulin – at least not right away. If I hadn’t tested and I just shot her up with 1.7U (this week’s preferred dose), she might have gone low enough to be hypo and need treatment. Or she might have dipped low and her pesky liver would get all excited and send out glucose (or make some other organ send out glucose, I can never get that part straight). Her liver always sends out too much, and she goes crazy high for days on end. I hate that.

So, 127 warrants special consideration. Do I skip a dose, and wait until tomorrow and see where her number is? That’s a very safe course, but it has its drawbacks, the main one being that I lose the overlap of insulin doses that I’ve so carefully cultivated. (Cultivated to no avail, apparently, judging from her recent streak of high glucose.)

Do I wait a while, see what her glucose is in a couple hours? That’s a good plan, but a late shot screws up her schedule. Or, do I pick a token dose, shoot her now, and hope it’s not too much? Nah. I’ve done that before with less-than-optimal results.

The hell with the schedule. I fed the cats and figured I test her again when I got back from swimming. But since Isabella was standing in the kitchen expecting an injection at the usual time (expecting a treat, more like), I gave her a treat and poked her with a capped syringe. A little placebo, just in case.

Four hours later: 177. Hmmm. That’s a surprise. I expected much higher, based on elapsed time since her last dose and the meal. Did Mr. Pancreas decide to deal with her postprandial glucose spike? (If so, thank you Mr. Pancreas. Nice to hear from you from time to time.)

Now I really have to decide. Insulin or no insulin? She’s rising, but not skyrocketing. I don’t want to lose all traces of overlap. I also don’t want to spend a sleepless night with a howling hypoglycemic cat.

I gave her a half unit. And more food (in case Mr. Pancreas really is awake today.) Hopefully this decision won’t keep both of us awake all night.

Such is life with feline diabetes