Having survived sedation dentistry, and sobered up for a few days anticipating the ramping up of the school year, I nearly killed myself with insulin. Here’s what happened:

At about 9:59 PM on August, 19, 2010, having enjoyed a movie (“Pretty Bird”) and seen Del off to bed, I settled down to the PM rituals: testing my blood sugar and taking the overnight dose of insulin. As I noted in the previous post to this blog, my overnight insulin is a glargine. It’s manufactured by Lantus, and is sometimes referred to by that name. 

The idea of the glargine insulin, in strictly layman’s terms, is to provide a base-level insulin that makes up for the body’s lack. In the normal person, the body has a complex mechanism that maintains a homeostatic level of sugar (glucose) in the blood. In the diabetic, this mechanism has been corrupted, allowing blood sugar levels to rise. 

I use (at the time of the incident I describe) 28 “units” of insulin glargine per day, and I take this dose before bedtime. I use a syringe that has a 31 gauge needle and the needle is 8mm in length. The syringes have a capacity of .5 mL (cc=mL.) The insulin comes in two strengths, U-100 and U-500. I use U-100. The syringes are marked on the side with “unit” markings. I don’t think about most of this, of course, when preparing a dose. I just grab the vial of U-100 insulin, take the little orange plastic caps off a syringe, use an alcohol swab to sterilize the cap of the vial, cock the syringe, insert it into the vial and void the air into the syringe. The insulin is packed in a vacuum. Enough air must be injected into the vial to allow the insulin to be drawn into the syringe. To inject 28 units, I inject at least that much air. Then I have the vial in hand with the syringe, usually in one hand. Now I use the swab to sterilize the injection site in my abdomen. I try to keep in mind where the last site was so that I’m not injecting in the same place. Next, I insert the needle into my flesh and push the insulin in by pushing it’s plunger. 

It seems like it might hurt, and sometimes it does when I’ve gotten too much alcohol on the site, or I’m careless with the needle and get it in at a strange angle. But if all goes according to Zen, it’s actually painless. And in the several years I’ve been doing this, it’s gotten to be automatic. 

I also use insulin that synthesizes the body’s own and this must be done in response to eating. The more carbs in the meal, the more of this Humalog insulin must be injected. I always inject after eating, that is, post-prandial. After a big meal, I inject no more than 12 units of the U-100 Humalog. Humalog insulin is a brand name of the Lilly Corporation, by the way. The name suggests and analog of human insulin, and so it is. This is very different stuff, compared to the glargine I described before. It acts to lower the blood sugar in an arc over time. It’s action is rapid, reaching its full effectiveness about two hours after injection. The idea is that the blood sugar in a diabetic is raised by eating and it peaks about two hours after the meal. 

My total insulin regimen involves the overnight ‘base dose’ and as many injections of Humalog to cover what I eat. (If I don’t eat, I don’t need an injection of Humalog.)

In fact, there are other factors that effect this trajectory. If you eat and then exercise, the sugar is burned off to the degree that the exercise is aerobic. Work the machine and it does its thing. I think other things burn sugar, but these are my impressions as a diabetic human with a glucose meter, not proper science. I have noticed that concentrating on something burns some sugar. You can’t really say that writing is physical exercise, yet the act of writing (thinking, concentrating) burns more sugar than sitting in front of the television watching CNN. Watching Fox burns alot of sugar – it’s hard to underestimate the calories expended throwing shoes at the TV set. Playing a musical instrument burns more sugar than writing. Cutting the lawn clearly wins the prize. Any physical activity must be accounted for to use fast-acting blood sugar dropping insulin properly. For this reason, among a host of others, diabetics miscalculate and end up with low blood sugar.

Low blood sugar can be fatal, since the brain needs the sugar to function. This is very important to keep in mind, so I’ll elaborate. The brain, as the supply of sugar drops off below a certain level, starting at about 60 milligrams per deciliter (mg/DL), sends out a distress signal. The hands shake. Concentration diminishes. There may be visual effects, such as the tunnel effect or a graying out of the visual field. Below about 40 mg/DL, there is loss of consciousness and below a certain point, coma, brain damage, and death. The ramp down can be fairly rapid, or so “they” say.

Habit breeds sloppiness. The other night, we watched the movie, and I was on a campaign to cut back on insulin, taking advantage of the sore choppers that were the aftermath of the dental work. I had a little fruit juice (8 oz.) and a very low dose of Humalog while the DVD player was on pause. Finally, I got down to getting the insulin from the fridge for the overnight dose. I saw the Humalog, and switched it to the back and grabbed the Lantus. I did this on autopilot. I was thinking about…who knows what?

Taking the box with the vial into my work area, table spread with medical records, pill bottles, bills to pay, bills paid, the stuff of the day to day, I sat down and, still on autopilot, injected 28 units of…

…and still sitting there with the syringe plunged in, I noticed I had grabbed the wrong insulin! I’d injected myself with a whopping dose of Humalog! I raced up the stairs to tell Del about my fuck-up. I needed to wake her in the event a trip to emergency was necessary. She calmed me down. She hates my disaster response: she says I get that deer in the headlights look. Now I had the dying deer by the roadside look. I went to the fridge and started choking down the highest carb thing I could find: a fruit smoothie (delicious!). I tried explaining it all, as I have done above, while I sipped. She watches me doing these diabetes chores daily, but hasn’t really had to think deeply and seriously about it. (See the sedation dentistry story.) 

She got a pad of paper and made me write down what had happened, exactly and when. I did this with a trembling hand. Was I trembling out of fear or was the insulin kicking in? 

On the pad I wrote:

“mistake made w/ insulin 9:59P

took 28 units of Humalog Insulin. (Normal dose after eating is 12 units max.)

followed with fruit juice (80 grams, carb.) 10:51P”

Del promised to stay awake, and fell asleep within a minute on the couch. I am in insomniac, so you can’t imagine how I envy her sleep! BUt now, I felt sleepy myself. A good sign, really. But my two goals were: keep testing the blood glucose, and keep ingesting carbs. Stay awake. Be prepared to wake Del in the event of an emergency plunge. (Could I do it? She’s hard to get started from a dead sleep, and an emergency plunge would leave me disoriented. Let the testing begin.

On the pad I wrote:

“10:54 – 74 mg/DL.”

I searched the web for info. I found a page that matched my query “mistake made with insulin,” apparently as a fictional gambit of some sort.

“What happens when you take too much of the wrong insulin? You die.”

Some of the explanations were very detailed and accurate. Some inverted the terms hypo and hyper, but were otherwise telling the same story. Amusing, all in all, but not uplifting or reassuring.

“Go to emergency and get a drip.”

“11:16P – another 74 grams carbs in fruit juice.”

I found a site that was devoted to people on high doses of insulin. I learned about the uses of U-500.

If you can’t get enough U-100 in a syringe, you need a more concentrated form of insulin. U-500 is five times more concentrated than U-100. I again heard the stories of Endocrinologists blaming the patients for their diabetes and its escalation, as mine does. There are people who feel defeated as their need for insulin rises. With the insulin comes the side effects, primarily weight gain. It gets to be a vicious cycle.

“11:56P test: 108 mg/DL.”

Another site covered the same material again, but had been translated into mostly grammatical English from some foreign language. This site offered a snapshot of another nation’s health care system. Easier access to doctors, but more sluggish access to hospitals. People having gone into diabetic coma in the provinces are found after six hours, and upon admission, have glucose readings in the 1.2 range. Is this mg/DL or mmol/L? If it’s mmol/L – millimole per liter – then it’s 21 mg/DL. Either way, they have brain damage or don’t make it.

“12:08P test 73 mg/DL.” (That’s 4.05 mmol/L.)

I fitfully read an old copy of the “Atlantic Monthly.” I read William Langewiesche’s piece on the Columbia disaster for the second time this summer. I look up Linda Ham on the web. She’s not evil, just pushy. Does her conscience bother her? Are these appropriate thought for a dying person. The fruit juice is making me very gassy. I go up to bed and take my reading up there. I’m reading a 1950’s college textbook on writing. Organize your thinking into a logical sequence. I start to get shaky, and by now I know it’s not fear.

“1:08A test 50 mg/DL.”

“1:30A – bagel/peanut butter, cereal and 12 oz milk, more juice (30 g carb).”

It is now a struggle to stay awake, but I must. The book is heavy in my hands. I am full of too much (hopefully enough) food. I’ve been sucking on blood glucose tablets, each one fast acting but relatively weak. I find the Lapham Quarterly, volume 1, number 1, and read from the voices of the ages on war. There are other, messier ways to die.

“2:51A 105 mg/DL.”

I brush and floss and I fall asleep. 

When I wake up, Del is poking me to see if I’m alive. She’s getting ready for work. I’m seriously sleepy. My blood sugar, when I test it, is 160. It’s that cereal, that “multigrain flake carb and colon explosion.” Works every time.