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Medical Forum / Diseases and Disorders / Diabetes / August 2007Tight glucose control in hospitals and later outcomes
This is directed to those diabetics who have been admitted to the hospital recently (past 5 yrs): 1. Were you in the ICU? 2. Did you have surgery? 3. Did your doctors use 'tight glucose control'? Tight control meaning frequent sugar testing with correction Insulin scales to keep the sugar between 80 and 120 at all times, sometimes using an Insulin drip. 4. What effect did the tight control regimen have on you psychologically? Did it change your perception about your disease and its management? Were you more motivated to keep your sugars low after that hospitalization? 5. Did your A1C experience a sustained drop since that hospitalization? I ask these questions because of the mounting evidence of an association between tight glycemic control in the ICU setting and better sugar control after discharge from hospital. The real reason this happens is still a subject of much discussion. Let's here what you guys think. There is already good evidence that tight control improves ICU and peri-operative outcomes so that is not in question. | This is directed to those diabetics who have been admitted to the | hospital recently (past 5 yrs): | | 1. Were you in the ICU? No, orthropedic floor, but it started to over-fill, so those of us who were a bit more mobile, were moved to the cardiac floor. A few medical persons said they were going to use me for "motivation" for the heart patients to get them up and moving... they said, if I can get up and make myself move just 7hrs after a double fusion they should be able to as well. | 2. Did you have surgery? Yes, a bilaterial decompression, diskectomy at L3, lamectomy at L3-L4-L5-S1 and fusion at L3-L4-L5. | 3. Did your doctors use 'tight glucose control'? Depends on which doctor we're talking about. My GP and I talked about "tight control" prior to my surgery. My GP spoke with my neurosurgeon who agreed to allow me to maintain my own glucose control. My GP came by to check up on me during my 3 day stay. Now, the hospital Endo, the hospital made come see me as "policy" because I was a inpatient that was diabetic. She was a completel and utter moron! She came into my room, mumbled something, then asked what my glucose was running? I told her, she then scribbled something down and left. A bit later the nurse came in with a syringe and vial of "Regular" insulin. I asked what they thought they were going to do.. He said, the Endo instructed in my chart to give me a sliding scale of Regular insulin at XYZ time of day.. without regard to the fact that I was on a Insulin pump.. They knew I was on a pump, but the Endo ignored that factor. Each Nurse though, did ask me to explain the "In's and Out's" of my pump, spending close to a hour with each one at each shift change. | Tight control meaning frequent sugar testing with correction Insulin | scales to keep the sugar between 80 and 120 at all times, sometimes | using an Insulin drip. My tight control is to keep my glucose between 90-130 at all times. I'd have to say, I did get that at least 80% of the time. Sadly, I had to pain medicate myself with my home stash to get that though.. | 4. What effect did the tight control regimen have on you | psychologically? Did it change your perception about your disease and | its management? Were you more motivated to keep your sugars low after | that hospitalization? I was motivated to keep my glucose as low as I could to help promote good fast healing. I also took mega doses of Zinc. | 5. Did your A1C experience a sustained drop since that | hospitalization? hmm, yes, for a short time and went back to my "normal" afterwards a few weeks later. (normal is 6.6-7.4) | I ask these questions because of the mounting evidence of an | association between tight glycemic control in the ICU setting and [quoted text clipped - 4 lines] | There is already good evidence that tight control improves ICU and | peri-operative outcomes so that is not in question. Well as a T1, I can tell you there is a huge effect on the body and mind when your glucose is running high. (over 250) it not only causes depression but it causes the body not to allow itself to heal properly or quickly for that matter.. as well as having high glucose is a breeding ground for infection. That was my motivator. rk, t1 happy pumper > This is directed to those diabetics who have been admitted to the > hospital recently (past 5 yrs): [quoted text clipped - 17 lines] > this happens is still a subject of much discussion. Let's here what > you guys think. Well, being one of the guys, and since you asked, I think you're still trying to make this your personal forum with us as your fawning disciples. Was that any help? JOhn On Jul 27, 11:04 pm, "johnniemccoy@" <johnniemc...@NOSPAMhotmail.com> wrote: > > This is directed to those diabetics who have been admitted to the > > hospital recently (past 5 yrs): [quoted text clipped - 25 lines] > > - Show quoted text - Was that any help? Nope. I want your perspective. > On Jul 27, 11:04 pm, "johnniemccoy@" <johnniemc...@NOSPAMhotmail.com> > wrote: [quoted text clipped - 33 lines] > > Nope. I want your perspective. No, you don't. You want me to offer a "perspective" which you can then correct... that is, "set me straight on," whatever subject it might be. When you've been able to do that to each member of the group, one at a time, you will have established your place at the head of the table. You made that very clear in your initial post. It is your divine Mission to lead us out of the darkness. I, personally, am much impressed. JOhn > This is directed to those diabetics who have been admitted to the > hospital recently (past 5 yrs): [quoted text clipped - 20 lines] > There is already good evidence that tight control improves ICU and > peri-operative outcomes so that is not in question. I have been in the hospital a lot over the past five years, once in the ICU. However, only one of my hospitalizations was after I became diabetic. That was in May, and it was on the psych ward, not in the ICU. (I went to the p-ward before doing anything silly enough to get me in the ICU. None of my other recent hospitalizations were related to my bi-polar though--all were for infections... I was even asked if I was diabetic, but the answer was no, and my FBG of my last physical (march of 2006 was only 87, so not a concern).) As for diabetes management, anyone diabetic was automatically put on an ADA diabetic diet. I take insulin, so it didn't bother me much, though I kept getting more food than I ordered (all carb choices) cause I wasn't ordering right... I was given my insulin. My blood sugars were only measured pre-meal, not post. (I had an endo apt. after that and he said that was alright, that most people don't really know what to do with post meal numbers anyways. Plus, I've been in tight control (until recently) since starting insulin--BG's always between 80-110, so he said if I was getting burnt out, I could slack on the testing for a while, just not on the insulin.) The nurses and techs were impressed with my control because I only had a number over 100 like twice, and even then it was less than 110. The nurse who was assigned to me was a little reluctant to give me my novolog the day I was a tad low (67) before lunch. I knew after they tested my BG it was going to be about a half hour before lunch arrived, so I ate some ghram crackers so I wouldn't crash further before lunch came. I only asked for as much insulin as needed for the carbs I ate at lunch (I have or had or something a 1:30 carb ratio with the novolog). I told her I ate enough for the insulin and it was fine. (I was getting it after I ate rather than before because I didn't know exactly what I was going to eat until I ate. It depended on what came on the tray, what I felt like eating and what looked good. I ate in about fifteen minutes, so it didn't really matter. They did have a CDE come talk to me briefly, as I mentioned I hadn't yet been to a carb counting class, but was supposed to have gone. (I still haven't been, am signed up for one, but have to change it as I have to work that day...). I told her how strange I thought it was that they kept adding carbs to my tray. She agreed that the ADA diet was def. not right for all diabetics (though again, with my insulin use, it doesn't matter so much, I find (or at least back then, now I've got other issues going on..) that as long as I carb count correctly, I don't have to worry so much about what I eat...). She said that with the new dietary system, there are no overrides allowed, so you only get what you are allowed to have, and it can be hard for some. There was someone who was a Type II trying to control with diet and exercise. She was ordering extra protein options and less carbs, but the new computer dietary system wouldn't allow that and she kept getting more carbs and not all her proteins. This was frustrating to the CDE and to her, but there wasn't anything they could do about it?!!? Now, I would have been allowed to have my own meter and such and could have used it whenever I liked, but it was at home and not with me. I hadn't brought it to work with me that day as I had stopped using it and my insulin a few days earlier and I was told by my shrink that I was NOT allowed to go home for anything, but had to go straight to the E.R. and to the p-ward (or she'd send a crisis team out to take me there). So, I didn't have my meter. I presume had I been in for physical reasons, and had I had more severe blood sugar issues, I would have had more frequent testing, and had my sugars been running high I would have had more insulin. But I don't know. I know if I were at the hospital I normally go to (but not the one where people see my shrinks patients for psych stuff, so I guess it's the hospital I go to for physical stuff) I'd have had more frequent checks and if my endo were involved (because it was a diabetes or thyroid or whatever related admission) I'd have had plenty of insulin for very tight control. (My official rules are 80-110 morning fasting, and pre-meals, 90-140 two hours post meal and pre bed, but he likes that I'm almost never above 110, especially since (until recently) I've not had issues with hypos). I think his website also states that any BG above 140 in the hospital should be treated with insulin. Um, yeah, so that's my experience with the hospital and diabetes management. Emily > This is directed to those diabetics who have been admitted to the > hospital recently (past 5 yrs): > 1. Were you in the ICU? Yes, 4 months ago I was in the Shock & Trauma ICU. > 2. Did you have surgery? No. > 3. Did your doctors use 'tight glucose control'? > Tight control meaning frequent sugar testing with correction Insulin > scales to keep the sugar between 80 and 120 at all times, sometimes > using an Insulin drip. Yes, in the ICU they did attempt to keep me between 80 and 120. Most of the time I was there I was on either no feeding, IV feeding or a feeding tube. I was in a coma most of the time I was there, but my husband was there almost the whole time and he told me how they worked to keep my blood sugar in tight control. I did spend 2 awake days there, but I wasn't fed much during that time because they just weren't nearly as good at taking care of awake people as not awake people :-) They did try to keep my blood sugar good during that time still, but there was one mistake where glucose was put in the IV after I was eating which spiked me high. Since others have commented on their control when not in the ICU, I will say that they did not attempt tight control outside of the ICU once I was sent to a regular hospital bed. There they only checked blood sugars before meals, and never checked after meals. > 4. What effect did the tight control regimen have on you > psychologically? Did it change your perception about your disease and > its management? Were you more motivated to keep your sugars low after > that hospitalization? I don't think the tight control regimen really had any effect on me psychologically. I had already done tight control during my pregnancies, so knew about it, and I already knew about how it would reduce complications too. What really had an effect on me was that I had nearly died because I had not kept my diabetes under tight control before my stay in the ICU. With 3 small kids I just felt like it was too hard for me to take as good of care of my diabetes as I should because I was so busy, so I was letting myself just test once or twice a day and pull down highs with insulin and I was taking basal insulin NPH at night, so that meant I was potentially high much of the time that I wasn't checking. I was eating very low carb (about 30 a day), so excessive carbs were not an issue, but I think I actually have double-diabetes, so I have a definite lack of insulin as well as having insulin resistance. The main thing is that poor control probably allowed an infection I had which was a boil to get out of control and get into my bloodstream which gave me Septicemia (blood poisoning). That shot my blood sugars up to 700 at admission to the ICU. In the 4 days before admission to the hospital I had not tested at all because I was out of test strips. I had been using Walmart test strips and I lived a 2 hour drive to a Walmart. I was planning on getting the strips when I went to an endodontist appt. near the Walmart, but ended up in the ICU the day before that appt. I was in Septic shock and DKA upon admission to the hospital. So, basically that hospital trip taught me that my diabetes could kill me quick, not just give me long term complications and perhaps shorten my lifespan somewhat. That was what made me decide to do tight control from there on out. So, now I do attempt real tight control. I almost always have it now, but I sometimes have unexpected highs or lows. It's tough to always get it right. > 5. Did your A1C experience a sustained drop since that > hospitalization? Well, I have only had my A1C tested once since then, and it did drop. I am sure it has dropped even more since then. It was when I had been out of the hospital for 5 weeks when we tested it and I was having a tougher time at first with tight control. My body was pretty out of whack at first, like one morning after eating an orange my blood sugar went over 400, then I overcorrected and shot too much insulin and spent half the day eating intermittently to correct that. I also could not tolerate hardly any protein for about a month after the incident. It was disgusting to me. Now, I am in a pretty good groove of knowing what I can eat and how much insulin to inject with it, and I am eating what this group would consider low carb, about 80 or 90 carbs a day. > I ask these questions because of the mounting evidence of an > association between tight glycemic control in the ICU setting and > better sugar control after discharge from hospital. The real reason > this happens is still a subject of much discussion. Let's here what > you guys think. I think that having tight control in a hospital setting at all could help convince people to maintain that tight control after. I would presume that the nurses and doctors implementing the tight control would probably talk it up, and talk about how it reduces complications. I think some people might come out believers. It might also help to show people that tight control is possible at all. I imagine that so many diabetics don't even realize that it is possible. I know that besides in the ICU and during pregnancy, I have actually been discouraged by doctors from doing true tight control, and they have been very impressed by so much less than tight control from me, so how would anybody who doesn't surf the web or get into the ICU or get pregnant even know it was possible. KC > > This is directed to those diabetics who have been admitted to the > > hospital recently (past 5 yrs): [quoted text clipped - 19 lines] > good during that time still, but there was one mistake where glucose was put > in the IV after I was eating which spiked me high. It is more likely that orders were not clear to stop dextrose containing IV fluids once you started eating. The dextrose was necessary to keep your liver from depleting amino acid pools to make glucose needed by your brain. > Since others have commented on their control when not in the ICU, I will say > that they did not attempt tight control outside of the ICU once I was sent > to a regular hospital bed. There they only checked blood sugars before > meals, and never checked after meals. The latter is standard of care because glucose-lowering medications should be administered only before and not after meals to avoid risk of hypoglycemia. > > 4. What effect did the tight control regimen have on you > > psychologically? Did it change your perception about your disease and [quoted text clipped - 14 lines] > double-diabetes, so I have a definite lack of insulin as well as having > insulin resistance. Complete lack of insulin would mean frequent ICU care for DKA with basal NPH only at night. > The main thing is that poor control probably allowed an > infection I had which was a boil to get out of control and get into my [quoted text clipped - 5 lines] > near the Walmart, but ended up in the ICU the day before that appt. I was > in Septic shock and DKA upon admission to the hospital. Sad to read about this happening to you. You were at higher risk from immunocompromise from **both** hyperglycemia and the pro-inflammatory cytokines coming from your VAT. > So, basically that hospital trip taught me that my diabetes could kill me > quick, not just give me long term complications and perhaps shorten my > lifespan somewhat. That was what made me decide to do tight control from > there on out. So, now I do attempt real tight control. I almost always > have it now, but I sometimes have unexpected highs or lows. It's tough to > always get it right. This won't get easier until you lose your VAT and are no longer insulin resistant. This would be my hope for you. > > 5. Did your A1C experience a sustained drop since that > > hospitalization? [quoted text clipped - 7 lines] > intermittently to correct that. I also could not tolerate hardly any > protein for about a month after the incident. It was disgusting to me. You may have has some gastroparesis. > Now, I am in a pretty good groove of knowing what I can eat and how much > insulin to inject with it, and I am eating what this group would consider [quoted text clipped - 17 lines] > would anybody who doesn't surf the web or get into the ICU or get pregnant > even know it was possible. The tightest control happens when the insulin resistance is gone. May GOD bless you in HIS mighty way making you healthier (hungrier) than ever: http://HeartMDPhD.com/PressRelease Prayerfully in Jesus' awesome love, Andrew <>< -- Andrew B. Chung, MD/PhD Cardiologist > > This is directed to those diabetics who have been admitted to the > > hospital recently (past 5 yrs): [quoted text clipped - 95 lines] > > KC Thanks for the insight. Diabetics admitted to the ICU who are not 'tightly controlled', do not experience the same post-hospitalization benefit that we see in the 'tightly-controlled' ones. I think the point about Diabetics actually coming to the realization that tight control is possible, is a very good one. The 'fear factor' is probably not a determining factor here because both groups of Diabetics experience the same ICU fear. It'll be interesting to see the results from all the ongoing studies looking at different variables that may influence the post-ICU behaviour change. > Thanks for the insight. Diabetics admitted to the ICU who are not > 'tightly controlled', do not experience the same post-hospitalization [quoted text clipped - 5 lines] > from all the ongoing studies looking at different variables that may > influence the post-ICU behaviour change. I have a cynical attitude towards hospitalization. I expect those who achieve tight control in the hospital do so because they insist on it, not because of the treatment by the hospital. Thus they already know about it. A bit over a year ago, I was hospitalized for acute pancreasitis. The treatment is nothing by mouth and pain meds. So I had an IV to keep me hydrated, and had to argue with 2 or 3 different doctors at various points that I ought not be getting a glucose solution, saline was fine. One insisted I needed the calories... although I am overweight and unlikely to starve to death in a few days with no calories. My bg was over 300 upon admission and their preferred treatment was to put more glucose directly into my blood. Morons. I recently had a heart attack. I had an emergency angioplasty which was not successful in clearing the blockage and then put on IV heparin for a week prior to a CABG. Apparently, heparin only comes in a glucose solution, so I didn't argue about that. However, the nurses in the CCU were concerned about me "eating like a bird." What this meant is when they brought my tray, I ate the omelet and salad, but left the cereal, banana, rolls and baked potato untouched. Even stoned on all the drugs they had me on, I knew eating that crap wasn't going to be helpful. When I was moved from the CCU, I had my husband bring me an electric camping fridge full of fresh veggies, meats, cheeses and cream for my coffee. He ate the ADA level of carbs they provided on my tray at each meal as he was pretty much there more than the allowed visiting hours - he "worked" longer shifts than the hospital personnel did. So basically, I ate the food he brought in and he ate what was on the tray. They *knew* we were doing this, but they still wrote down on my chart that 80% of the tray food was eaten for a particular meal! I guess there was no checkbox on the chart for "patient is eating her own food and ignoring our trays completely". I wasn't exactly a great participant in my health care, being pretty much stoned the whole time. I have huge losses of memory for things that happened, many of which my husband has filled in for me. But in spite of not running on all cylinders, when the internist complained about not being able to get my bg down, that they were going to have to postpone my surgery cause they couldn't lower my bg, I'm the one who suggested a basal/bolus routine. I knew *nothing* about insulin at the time, and couldn't have told you which insulin was which, but I knew there was such a thing as basal/bolus. They put me on a Lantus/ Novolog routine and got my bg fixed in plenty of time for the scheduled CABG. I was discharged with instructions for a Lantus/Humalog regime. My current internist is one of the group that began treating me in the hospital. He does not know as much about diabetes as I do. That is not an insult to him, he is a young guy who probably wasn't in college when I was diagnosed - and I was a PhD candidate in biochemistry when I was diagnosed - with access to a full medical library years before PubMed was on the web. Also, he has to keep himself educated on a whole pile of diseases whereas I only focus on diabetes. The internist group's recommendations are for the normal ADA diet and to keep bg under 200. My doctor is aware that I have tighter goals than that and that I am on a stricter diet than they typically recommend to their patients. He doesn't hassle me about it and listens to my concerns respectfully. We discuss things and make decisions mutually. But I kind of take the lead on the diabetes thing. The control I've achieved has very little to do with him. Hell, they only instructed me to test fasting and preprandials... I'm the one testing postprandials on my own so I can see how my regime is actually working. And I've learned GOBS about the various insulins. My insulin needs dropped dramatically the first couple months out of the hospital, and other than my first hypoglycemic episode when I called and got instructions to reduce my Humalog, I've made all the further insulin adjustments on my own. My doctor supports me in that and basically "prescribes" whatever I've decided to do. I tell him what I've decided and why, sort of for a sanity check, and he usually agrees. That is quite good enough for me, he doesn't have to be a tight-control doctor himself as long as he helps me with my goals. Finding a doctor who is into tight-control is rather tough, I'm quite happy to have one who doesn't hassle me about it. So... based on my own experience, I'd guess that those who had tight control in the hospital did so on their own - not with the assistance of the hospital. If there are hospitals around that actually make tight control a goal, they aren't located in central PA! I think attaining tight control after hospitalization just means patients keep doing what they were doing before being hospitalized. > So >basically, I ate the food he brought in and he ate what was on the >tray. They *knew* we were doing this, but they still wrote down on my >chart that 80% of the tray food was eaten for a particular meal! I >guess there was no checkbox on the chart for "patient is eating her >own food and ignoring our trays completely". LOL! Should do... that's exactly what we did, before dx. I haven't been hospitalised since, thank goodness. >Finding a doctor who is into tight-control is rather tough, I'm quite >happy to have one who doesn't hassle me about it. <envy> Mine doesn't exactly try and hassle me about the results, but tries to take away my strips prescription every time I go near him. It's a real PITA remembering to muster test,test,test arguments BEFORE actually getting to talk about whatever's worrying me. Nicky. T2 dx 05/04 + underactive thyroid D&E, 100ug thyroxine Last A1c 5.6% BMI 25 > <envy> Mine doesn't exactly try and hassle me about the results, but > tries to take away my strips prescription every time I go near him. > It's a real PITA remembering to muster test,test,test arguments BEFORE > actually getting to talk about whatever's worrying me. They prescribed 4 strips a day for me because of the insulin. I'm supposed to adjust my insulin dosage based on preprandials and then do a bedtime reading as well. I presume the purpose of the bedtime reading is to compare to fasting wrt DP, but I already *know* I have a bad case of DP, so I rarely bother with a bedtime reading. I find with the same Humalog dose, I can tolerate only about half the carbs at breakfast as I can tolerate at lunch or dinner. I just pay for the extra strips for doing postprandials myself. Not worth arguing about, ya know? As far as *they* are concerned, they "measure" my control with the HbA1c and think every 3 months is sufficient. I want more data than that, so I just pay for it myself. If you get better control with strips than without, that seems to me to be sufficient argument for keeping the strips. >> <envy> Mine doesn't exactly try and hassle me about the results, but >> tries to take away my strips prescription every time I go near him. [quoted text clipped - 19 lines] > If you get better control with strips than without, that seems to me > to be sufficient argument for keeping the strips. Hmm... I guess I'm lucky then that my doc prescribes testing up to eight times a day and 250 strips a month. I had 200 strips a month and testing up to six times a day, but when I started insulin, I was using more strips, cause I was convinced I was going hypo all the time (usually I'd be 140 or so, but I was so not used to those low numbers after running so high for a few weeks). He immediately called in the 250 a month script for me. I have a friend who goes to the same endo clinic and gets 300 strips a month. I know some insurances won't pay for that many strips, even if there is a script for that many, but mine still does thankfully. I don't always test that much these days, but I used probably a whole 25 strip vial on Friday when I was going low all day long. And, I know I tested more than eight times a day prior to that when I was running high from my infection. (I would correct if I was high at 2hrs PP, and sometimes I was, towards the end though, I'd figured out fairly well how much levemir to take and how much novolog to use with a given meal. Sometimes though, I'd be well within range 2hrs PP, but be close to 200 at the next meal!! (then I'd up the levemir..) My doc firmly believes testing is the key to tight control. He also though gave me permission to slack off on testing at my last visit if I was getting burnt out. I'd recently been to the psych ward, but by the time I saw him I was heading into a manic episode... If you have good control, he doesn't care as much how often you test. If your control could be better, you'd darn well better be testing often! Emily > Hmm... I guess I'm lucky then that my doc prescribes testing up to eight > times a day and 250 strips a month. I had 200 strips a month and testing [quoted text clipped - 8 lines] > probably a whole 25 strip vial on Friday when I was going low all day > long. Ha! I know about that. My first hypoglycemic episode, I was FREAKING. Take a glucose tablet, test, take another tablet, test, eat this nasty glucose gel, test, etc. Turns out I was testing faster than I could've expected the glucose to hit. I was being ridiculous. It's *shocking* to suddenly have to deal with being too low after all those years and years of only ever worrying about being too high. The last 3 or 4 years before I went on insulin, I only ever saw a 2-digit reading *once*. Seeing numbers actually going too low is like... WTF?!?! EEEK!!!! I got my plan worked out after that. I know how much Sweetarts raises me, based on how much glucose is in each and my bodyweight. So... a few weeks after the first episode, I vomited my lunch after having taken the appropriate Humalog to cover it. I tested and was low. I took enough Sweetarts to raise me to about 95 or so, figuring it's better to overshoot a bit than not. And I waited an hour before testing again... just having faith that eating sugar WOULD raise my bg. I mean, how could it not? My next preprandial was a bit low (68 or so), so I just ate a bit more carb at that meal and cut the Humalog a bit. > And, I know I tested more than eight times a day prior to that > when I was running high from my infection. (I would correct if I was > high at 2hrs PP, and sometimes I was, towards the end though, I'd > figured out fairly well how much levemir to take and how much novolog to > use with a given meal. Sometimes though, I'd be well within range 2hrs > PP, but be close to 200 at the next meal!! (then I'd up the levemir..) Yeah, sometimes I have to test a lot more often than other times too. The notion of needing X number of strips per day is kinda bogus... I need however many I need. > My doc firmly believes testing is the key to tight control. He also > though gave me permission to slack off on testing at my last visit if I > was getting burnt out. I'd recently been to the psych ward, but by the > time I saw him I was heading into a manic episode... If you have good > control, he doesn't care as much how often you test. If your control > could be better, you'd darn well better be testing often! I like your doctor! I get burnt out too. The other day, I went in for some fasting blood work and wanted to stop and get something to eat afterwards as it was almost noon and I was hungry. Hubby asks if we can hit a drive- through... and I'm like... uh, no. I have to test, figure out the carb and protein of the meal, take my insulin, set my timer for the postprandial... I can't just *eat*. I'd been low-carbing for many years before and could pretty much just eat... I knew what worked for me. Now, eating is a lot more complicated as I'm a newbie all over again. I assume it will get better as I get more experienced. But... even though I'll learn and it'll require less attention, unless it's sugar-free jello or something equally non-caloric, I am unlikely to ever be able to "just" eat again. I've spent several hundred hours in the past couple months reading about insulins. And I've been testing more than I ever have at any time in my life. But some days, I am just SICK AND TIRED of being diabetic. >> Hmm... I guess I'm lucky then that my doc prescribes testing up to eight >> times a day and 250 strips a month. I had 200 strips a month and testing [quoted text clipped - 19 lines] > reading *once*. Seeing numbers actually going too low is like... > WTF?!?! EEEK!!!! This wasn't my first low, but I've not had many. The issue was, I was ALWAYS low. I ate, and 1-2hrs PP I'd feel kinda shaky, and I'd be somewhere in the 50s. So I'd have something to raise me quickly (a glass of milk usually, or 1/2 a pop or whatever) and then I'd have a snack to keep me up. (if I just treat and don't eat something else, I usually crash again..). Well, 1-2hrs after the snack, I'd be shaky and back down in the 50's! I must have eaten enough calories that day for two or three days!! Finally, my last snack was a very unhealthy fried cheese, onion rings and a bit of real pop (used to be my favorite treat drink, but now I've found it doesn't taste all that good to me, I'm so used to not having sugary drinks that they are all too sweet!), I managed to not go low. I was at 100 or so two hours later (and I didn't spike high either, and I didn't use any novolog for it!). If it had been only one hypo,I'd have been fine,and used maybe two or three extra test strips--one to test that I was hypo, one to test that my fast remedy had worked, and one to test that my snack hadn't spiked me. > I got my plan worked out after that. I know how much Sweetarts raises > me, based on how much glucose is in each and my bodyweight. [quoted text clipped - 8 lines] > My next preprandial was a bit low (68 or so), so I just ate a bit more > carb at that meal and cut the Humalog a bit. Yeah, sounds about like what I do. I do keep hard candies (usually, need to restock) in the case with my glucose meter. That way, when I'm at work--or out and about--I've got something handy to easily raise the BG. I generally prefer to drink a bit of pop or milk. Milk's my fave, cause it has healthy stuff in it, pop (if drunk with a straw) is less harsh on the teeth than chewing up hard candies. Though I try to test and make sure the fast remedy worked, and not too well, and I try to have abit of a snack with/after it. I figure my teeth get coated in enough sugar when I'm running high, don't need to abuse them when I'm low too. (usually lowish carb, so I don't inject, and with some protein and good fats. I've got a trail mix I keep at work which is three bags of nuts (one of almonds one of cashews and one of brazil nuts) and one bag dried pineapple. It has far more nuts than pineapple, so it doesn't spike me, but it has plenty of good fat and protein to last me a while.) I don't often get a chance to test after at work--if we get swamped I don't have time for much. Retail isn't exactly a diabetic friendly career. >> And, I know I tested more than eight times a day prior to that >> when I was running high from my infection. (I would correct if I was [quoted text clipped - 6 lines] > The notion of needing X number of strips per day is kinda bogus... I > need however many I need. Exactly! But, since I don't always use eight strips a day (most often not I think) I've got extras for when I need to test more often. If I ever get the stomach flu or something, I know I'll be testing WAY more than eight times. I'll probably also have the Endo's number on speed dial so that if things go really wonky, I can speak to a CDE quickly. (I've not yet had a major stomach bug since being diagnosed, and the thought kind of scares me. I did have some nausea/vomiting while discontinuing a psych med, but it was only briefly in the mornings, and then I'd be better). >> My doc firmly believes testing is the key to tight control. He also >> though gave me permission to slack off on testing at my last visit if I [quoted text clipped - 4 lines] > > I like your doctor! I like him too! > I get burnt out too. The other day, I went in for some fasting blood > work and wanted to stop and get something to eat afterwards as it was > almost noon and I was hungry. Hubby asks if we can hit a drive- > through... and I'm like... uh, no. I have to test, figure out the > carb and protein of the meal, take my insulin, set my timer for the > postprandial... I can't just *eat*. I know how you feel. Actually, I can hit a drive through now, but it has to be only a few certain restaurants whose food I know, and I have to order the same thing. I've at least learned the carb count of some stuff, and what it does to me (generally). I always have my meter with me,so I can test easily and quickly enough... The one thing I lamented with this diagnosis is that I would never be able to JUST EAT again. > I'd been low-carbing for many years before and could pretty much just > eat... I knew what worked for me. Now, eating is a lot more [quoted text clipped - 4 lines] > it's sugar-free jello or something equally non-caloric, I am unlikely > to ever be able to "just" eat again. I'm learning, and I don't have to think so much about eating, but I do think I to will never be able to just eat again. Actually, when first diagnosed, I was terrified that I would develop an eating disorder. (My sister is recovered from a pretty severe one (she grew up in a different family than I, she became my sister when I was twenty and she was eighteen), but we always thought I should have gotten one. My mom's family is quite food oriented, but in a mostly healthy way, and I think that largely saved me, even though they are all weight worried as well. My dad's family is just nuts, but his sister sometimes dabbles in anorexia (she has other mental health issues that are dominant) and his dad was found to be quite anemic and low on protein etc. when he broke his hip. Turns out he'd been starving himself to try and fit into his girlfriends late husbands clothes that she had given to him. They were a couple sizes too small for him... Sigh.) I have had periods of disordered eating in the past but never an eating disorder. The time I went longest without eating was more of a pathetic suicide attempt rather than an eating disorder. For the most part, I had always eaten when I was hungry and stopped when I was full, and paid attention to portion size (and allowed a little time after eating a normal portion to become full) and had a healthy body/weight/food relationship. I can become obsessed about things though, and I was terrified at first that I would become food obsessed with the diabetes and carb counting and all that stuff. Fortunately, I haven't really. I have started eating even healthier, and trying out new low carb recipes etc. (I've found I can eat pretty much what I want as long as I inject for it, and certain things cannot be eaten alone, but I don't like to eat tons of carbs and take tons of insulin. (o.k. so 120gm carbs at once would only be four units of novolog for me under normal circumstances, but still 120gms is overkill and I think the less insulin I have to use the better). > I've spent several hundred hours in the past couple months reading > about insulins. And I've been testing more than I ever have at any > time in my life. > > But some days, I am just SICK AND TIRED of being diabetic. I hear you on the sick and tired of being diabetic, and I've only been at it since January. I haven't researched insulin all that much, mostly what I've learned from boards like here and the ADA and Joslin's. I was started on levemir for my basal and novolog for my fast acting and about three days after I started, I was in a range of 80-110 most of the time. It did take a bit of adjusting from there to find out what was right for me. I never went hypo as far as I tested during that period, but I did wake up a lot on the low side (seventies) and I also sometimes would wake up in a sweat and feeling all weird, and my bg would be fine (like 80-100), but I think I would wake up after a hypo and a liver dump. Once I got down to three units of levemir at night I was in good shape, and that didnt' happen to me. I crept back up to five units when my morning bg was hovering around 110. (I'm allowed to be 110 but not higher, however I prefer to be under 100, so I adjusted upwards). Now, I'm at four units, (went back down again), and seem to be good. I think some of why I didn't go super hypo on the insulin but was able to adjust it down was that I'd been running REALLY high right before I got it. (200-400 and even into the 500's, and trending upwards, which is why my endo put me on insulin) So, I think some of my beta cells were injured by that, but once I got back into a good range on the BG they were able to repair themselves and put out more insulin. Dunno. I've done enough insulin research to know that the mixed insulins really don't make much sense, and the basal bolus method coupled with dosing by carb counting for the bolus makes the most sense. Oh, and the method one co-worker is supposed to use--follow a strict diet, test two hours after, and if high correct with insulin. She doesn't use insulin before meals, only if high after! (she's a type two, and I think the insulin is supposed to be temporary, but the whole using it to correct highs rather than prevent them doesn't make any sense to me!) My endo was way ahead of me on all of that though. My first bolus instructions were a sliding scale based on pre-meal BG readings, but that was again when I was running VERY high, and it only lasted over the weekend, from when I got insulin from the CDE and when I saw my endo. Then he switched me to carb counting. If I didn't have the BG numbers I like, I'd def. be doing more research, but since I can stay between 80-110 except when I have an infection, I'm not going to try and change anything. Of course, I keep waiting for that to change, for me to either stop making insulin or become more IR or whatever my body is going to do with this diabetes (my endo is still puzzled by me). I was afraid that I was doing that a bit since I was using three times as much novolog as usual when I had the infection. (eventually three times as much levemir too, ten units at night, five in the morning). But, now that the infection is gone, I'm back down to a low carb ratio (1:30ish, maybe not quite that now, more like 1:25 or so, and I round up rather than down--but I can do half units now too), and I'm back to only four units of levemir at night. I hope you continue to figure out your insulin usage/needs, and that you don't get too burnt out in the process. My next step is to really be diligent about a food log/BG log, for about a week or two, so I can make an appointment with the dietitian and maybe get a food plan to lose some weight. I gained about ten lbs since starting insulin. It seems to have stopped there, but I'd like to lose those ten lbs and maybe five or ten more--I also gained ten lbs when my thyroid went from being over active to underactive. I have a diabetic co-worker (actually there are four of us at work on insulin) who told me I should hope I don't have to go onto insulin, because it will make me gain weight, and it is not possible to diet while on insulin. I'm not sure how true that is, I can see how severely restricting calories would not be good, but I think I can find an eating plan that will allow me (along with exercise and a healthy lifestyle) to lose some weight. Emily Emily, I like "talking" with you. I haven't run across many Type 2s in my quest for insulin knowledge; mostly been talking to Type 1s. And while they tend to know LOTS more about insulin than me and have quite a bit more experience with it, it's NOT the same thing, you know? Also, I'm depressed too. Not that I'm glad you're depressed, but... it's nice to have someone to relate to. They told me in the hospital that depression was a common side effect of CABG. And I just laughed my a.s off at them. Gosh, splitting my sternum open and doing all these gross and horrible things to my body and being helpless and in pain and not able to do anything is DEPRESSING? Who'd have GUESSED that? ;) > This wasn't my first low, but I've not had many. The issue was, I was > ALWAYS low. I ate, and 1-2hrs PP I'd feel kinda shaky, and I'd be [quoted text clipped - 12 lines] > test that I was hypo, one to test that my fast remedy had worked, and > one to test that my snack hadn't spiked me. Sounds like your basal may have been too high. They lowered my Humalog after my first hypoglycemic episode. But afterwards, that was one of my first clues about my Lantus being too high... one day I got up, tested fasting, then didn't eat for a few hours cause I wasn't hungry - and I was low at my next preprandial. A few days later, I went a long time between lunch and dinner and again went low. > Yeah, sounds about like what I do. I do keep hard candies (usually, need > to restock) in the case with my glucose meter. That way, when I'm at > work--or out and about--I've got something handy to easily raise the BG. > I generally prefer to drink a bit of pop or milk. Milk's my fave, cause > it has healthy stuff in it, pop (if drunk with a straw) is less harsh on > the teeth than chewing up hard candies. I don't know what your candy is made from, but milk sugar is lactose (a disccahride that once digested is only half glucose) and pop is largely fructose, so these won't raise your bg as fast as just a glucose source. Not that you should buy that disgusting, overpriced glucose gel crap. I don't see how they sell the stuff, you'd think anyone who used it once would RUN from ever buying it again. Yech. I picked Sweetarts for a few reasons: first, they are nearly all glucose (dextrose is the same thing). Second, they are tolerable tasting, unlike that nasty gel. Third, they aren't actually GOOD tasting, so there's no temptation for me in having them around. Fourth, they contain a very low amount of glucose, so I can titrate pretty precisely so I don't overshoot too much. And finally, there's almost nothing to them, so odds are quite good that I will be able to keep them down even when ill (the episode I discussed where I vomited, I waited an hour to test to let my stomach settle a bit, then took enough Sweetarts to bring me back up and it worked out fine). I feel much more *controlled* about hypoglycemia now having a very specific plan and knowing exactly what to do. > If I > ever get the stomach flu or something, I know I'll be testing WAY more [quoted text clipped - 4 lines] > discontinuing a psych med, but it was only briefly in the mornings, and > then I'd be better). I am scared of that also. I mean, if I *knew* I was ill, I'd obviously skip both the meals and the bolus, but... if I take my bolus, lose the meal, and am sick enough to not keep the Sweetarts down, that's gonna be an emergency. Insulin is so ironic... keeping us alive with the potential risk of killing us. > I know how you feel. Actually, I can hit a drive through now, but it > has to be only a few certain restaurants whose food I know, and I have > to order the same thing. I've at least learned the carb count of some > stuff, and what it does to me (generally). I always have my meter with > me,so I can test easily and quickly enough... The one thing I lamented > with this diagnosis is that I would never be able to JUST EAT again. Yup. I *SO* get it! > I'm learning, and I don't have to think so much about eating, but I do > think I to will never be able to just eat again. Actually, when first [quoted text clipped - 19 lines] > would become food obsessed with the diabetes and carb counting and all > that stuff. I have ABSOLUTELY become obsessed with insulin and food counting and all that. It didn't worry me though, I KNEW it would happen. I've been obsessed about a few score things at various times in my life. And I have a passion for learning. And I'm a bit of a control freak, and this is something I can *do* something about - unlike the whole cardiac thing. I don't like the emotional sh.t like being depressed and thinking about how I won't ever be able to "just eat" again or being in pain and not being able to do much physically. Focusing heavily on the diabetes thang right now kind of gives me something rational to do, which is WAY preferable to feeling shitty that my garden is full of weeds and I can't do anything about it. > Fortunately, I haven't really. I have started eating even > healthier, and trying out new low carb recipes etc. I can't cook right now because I can't lift a skillet without pain. Hubby is caretaking me and I am very appreciative, but... he is not a cook. I can only ask for things of minimal complexity. So... there's lots of salads, cottage cheese, berries and such. Actual cooking... not so much. Heck, we're even buying frozen omelets... cause he can work a microwave! ;) > (I've found I can > eat pretty much what I want as long as I inject for it, and certain > things cannot be eaten alone, but I don't like to eat tons of carbs and > take tons of insulin. (o.k. so 120gm carbs at once would only be four > units of novolog for me under normal circumstances, but still 120gms is > overkill and I think the less insulin I have to use the better). I *completly* agree. All those years of being a regular old non-insulin-dependent Type 2, one of the biggest things that damages your health is the high levels of insulin you make due to the IR. I don't see any reason to take more insulin than I need. It's already a shockingly high dose with low carb - I don't even want to KNOW how much it would be if I ate a "normal" diet. I think this is one of the biggest differences between most Type 1s and us. Most of them don't see the point of low-carb cause they manage to cover a "normal" diet with reasonable amounts of insulin. when I left the hospital, I was on 81 units a day. That is a CRAZY amount of insulin... and that WAS with low-carbing! That being said... there is also the case of having been hypoglycemic and correcting and still being low at your next preprandial. That is the time to indulge in a bit of extra carbs... and it's so ironic to find yourself in a position where "cheating" on your diet is actually a good thing. ;) > (I'm allowed to be 110 but not higher, > however I prefer to be under 100, so I adjusted upwards). I like your doctor! I''m "allowed" to be 80-200. Obviously, under 200 is not an OK goal. I discovered that being in the 70s is not a hypo, I can be in the 70s postprandial and it's still in the 70s at the next preprandial. So I don't consider the 70's to be worth correcting for anymore - I just take less Humalog with the next meal. So I'm aiming at 70-120 myself. And staying pretty much there almost always. > Now, I'm at > four units, (went back down again), and seem to be good. I think some of [quoted text clipped - 4 lines] > but once I got back into a good range on the BG they were able to repair > themselves and put out more insulin. Dunno. I had the same experience. I went from 45u Lantus/daily and 12u Humalog/meal to 30u Lantus/daily and 6u Humalog/meal. Over 80u to under 50u in just a few weeks. My bg ran REALLY high for quite some time. This is embarassing to admit, but I'm just gonna do so anyways... I mentioned two hospitalizations about a year apart in my earlier post in this thread. The first one was for pancreasitis, which they never determined a cause for. However... whatever caused it, I lost bg control MAJORLY when it happened. I never saw a reading under 300 after that attack... even on the strictest possible low-carb and even fasting for a couple days. So... what did Ms. Brilliant Biochemist do about this? Well, I decided I must be sick so I'll just wait a while before testing again. When it was still high a few weeks later, I bought new strips. Later, I bought a new meter. I finally admitted my bg was really freaking out-of-control and I needed to be on insulin and... then decided to postpone it because we didn't have insurance, and because I don't know a good doctor in this town, and... well, I'll do something about it next week, or next month. And maybe I'll just buy insulin on my own, but I don't know how to give injections. Excuse after excuse after excuse. I "postponed" doing anything about getting on insulin not because of any of these "reasons", but because I was scared of insulin. Then... I kinda quit testing. EVERY time I tested it was over 300 and nothing I did made the slightest difference. I didn't want to think about it anymore. Part of it was that I have a massive needle phobia. You'd not BELIEVE how hard it was for me to learn to do bg testing and that's easy as you never even SEE the needle with a typical lancet. But part of it was just this refrain in my head... my dad was always diet-controlled, and then he went on insulin, and then he died. Not a *rational* fear at all... just this terrifying feeling that insulin = death I am personally convinced that sitting around being afraid of insulin and letting my bg run crazy is why I had the heart attack in the first place. Basically, my own stupidity attack caused the heart attack. So... while I was busy being afraid that if I went on insulin, I'd die... the fear itself nearly killed me. And it turned out that being on insulin is absolutely no big deal at all. I still get little minor twinges of fear when I look at the needle too long, but... there's less pain than with bg testing and it's just not much of a big deal. When you look at the risk factors for cardiac disease, no one ever mentions that being an idiot is one of them. Aside from confessing my idiocy, the point I was trying to get to was... my bg ran very high for a long time before it got corrected. So it's not too surprising that as my body rested up a bit from the damage of the high bg that I needed less insulin. I think this is a very common occurrence when people start on insulin. > I've done enough insulin research to know that the mixed insulins really > don't make much sense, and the basal bolus method coupled with dosing by [quoted text clipped - 9 lines] > insulin from the CDE and when I saw my endo. Then he switched me to > carb counting. I have heard of using bolus doses to correct. One day when I have a high preprandial, I want to take a small dose of Humalog, skip the meal, and see how much it drops me. Just so I'll *know* how much it takes to correct a high. It's sort of the other half of the equation: I know how many Sweetarts I need to correct lows, I want to know how much Humalog to correct highs. > If I didn't have the BG numbers I like, I'd def. be doing more research, > but since I can stay between 80-110 except when I have an infection, I'm > not going to try and change anything. Well, you've got a very good endo from what I can tell here. My internist is nowhere near as good so more of it is up to me. Though really, I kinda like it that way. It's given me a "hobby" to obsess about while I'm not capable of much. > Of course, I keep waiting for > that to change, for me to either stop making insulin or become more IR [quoted text clipped - 6 lines] > and I round up rather than down--but I can do half units now too), and > I'm back to only four units of levemir at night. I can't calibrate to half units. My Lantus dose is so large that the syringe just can't be that accurate. And the Humalog is via pen, which only allows whole units. > I hope you continue to figure out your insulin usage/needs, and that you > don't get too burnt out in the process. My next step is to really be > diligent about a food log/BG log, for about a week or two, so I can make > an appointment with the dietitian and maybe get a food plan to lose some > weight. I gained about ten lbs since starting insulin. I've been keeping a very detailed log... preprandial, how many carbs, protein and calories at each meal, 1 and 2 hour postprandials... and various notes. My next step is to become more consistent. I'm still in a lot of pain, and therefore have trouble sleeping sometimes, and my schedule is just wacked. I need to normalize my life a bit. I'm hoping to be able to decrease my insulin a bit further, but it will likely be much smaller decreases than I've seen thus far. I think I need to be a lot more consistent before I can do the smaller tweaks to my regimen. > It seems to have > stopped there, but I'd like to lose those ten lbs and maybe five or ten [quoted text clipped - 6 lines] > can find an eating plan that will allow me (along with exercise and a > healthy lifestyle) to lose some weight. You can lose weight on insulin. When I was in the hospital, I gained 20 lbs. Dropped them in just over a week after I got out. So I assume it was water cause I don't see either gaining or losing actual mass that rapidly. But I've lost another ten pounds since. I haven't been trying for weight loss, just obsessing about insulin and logging everything I eat. Sticking to low-carb and eating to my hunger, which seems to vary a great deal from day-to-day. Sure, insulin is the fat-storing hormone, but it doesn't mean being on insulin is gonna make you fat. But it's one of the reasons to not just eat a pile of carbs and take enough insulin to cover them - minimizing the amount of insulin you need is probably a help. I'm not sure how much carb I "should" be eating. So... I just stuck to what worked before I lost my bg control. That was about 50g (net)/ day, so I'm still doing that. Protein and calories varies wildly... heck, even the number of meals has varied a lot. Consistency is not something I've been achieving lately. I don't want to say it's easy... cause obviously that varies tremendously. It probably depends more on your IR than anything else. But I lost 10 lbs without even TRYING and I'm on WAY more insulin than you - so it's definitely possible! > Emily, I like "talking" with you. > [quoted text clipped - 11 lines] > and being helpless and in pain and not able to do anything is > DEPRESSING? Who'd have GUESSED that? ;) I am happy as a pig in mud. I walk around humming rediculous tunes all day. I'm almost always in a giddy mood. I smile at strangers and make them look uncomfortable. I feel like the sun shines on me 24 hours a day. I sincerly wish I could bottle some of how I feel and send it to you guys. I just really hate it that you're depressed. Tell you what.... reach out and pretend you're touching my hand. I'll see if I can will some it into you. Who knows? John <... BIG hugs !> Keep working on them paragraphs, Emily ! "Emily" <emsy_suzy@nospam.yahoo.com> a écrit ... >>> Hmm... I guess I'm lucky then that my doc prescribes testing up to eight >>> times a day and 250 strips a month. I had 200 strips a month and testing [quoted text clipped - 219 lines] > > Emily > But... even though I'll learn and it'll require less attention, unless > it's sugar-free jello or something equally non-caloric, I am unlikely > to ever be able to "just" eat again. I take boluses of Humalog for food, and I feel like I can just eat. Humalog is really fast acting, so I can take it after I eat if necessary. KC > <jackiepa...@gmail.com> wrote in message > [quoted text clipped - 6 lines] > I take boluses of Humalog for food, and I feel like I can just eat. Humalog > is really fast acting, so I can take it after I eat if necessary. I take Humalog also, but that's exactly why I feel I can't "just eat". I have to know my preprandial and the amount of carb and protein to figure the Humalog dose, and then set a timer to test the postprandials. This is not the same thing as before insulin, where I knew if I ate right, my bg was almost certainly OK. Ever leave the house without Humalog? I carry the meter and Sweetarts always, but... just going to run a couple errands and don't expect to be gone long, maybe an hour or two, so didn't bring the Humalog. And then there's traffic and long lines and it takes much longer than expected and you get hungry and realize... I don't have insulin, I can't just stop and pick something up. I *know* the whole insulin thing will become second nature with time, just as low-carbing had. But it hasn't yet and I need to really think about what I'm doing. And no matter how much easier it gets, it will never be knowing I can just grab a burger and throw out the bun and assume that's OK. I know T1s who had previously been on mixed insulins find the basal/ bolus routine very freeing. But going the other way, from not needing insulin at all to basal/bolus, feels very restrictive. >> <jackiepa...@gmail.com> wrote in message >> [quoted text clipped - 12 lines] > protein to figure the Humalog dose, and then set a timer to test the > postprandials. Ah, I don't take preprandial levels. They never had me do that when I was doing tight control for pregnancy diabetes, so I got in the habit of doing it this way. I actually have my own way of doing things now. I only take bolus insulin at bedtime (NPH, so it isn't active in the daytime). Then I take a whole bunch of humalog shots during the day for every carb I eat, whether meal or snack. I occasionally have checked if I went high when not eating, and my levels do go up, but I have never found it over 135 mg/dl, and I usually don't go that long without eating as I prefer the 6 snacks a day method really rather than meals at all. I prefer the freedom of the way I do it even though it is alot more shots. > This is not the same thing as before insulin, where I knew if I ate > right, my bg was almost certainly OK. [quoted text clipped - 5 lines] > expected and you get hungry and realize... I don't have insulin, I > can't just stop and pick something up. If you really get hungry, you can buy something super low carb to get you by, like a burger without the bun or some kind of meat sticks from a convenience store. I live in a super small town, so I frequently go out without my insulin, but there's no traffic to hold me up. As a matter of fact it is such a small town, there is not even any fast food here, and would be just as quick for me to get home to eat as to get to somewhere else to eat. > I *know* the whole insulin thing will become second nature with time, > just as low-carbing had. But it hasn't yet and I need to really think > about what I'm doing. Yeah, I forgot about the whole pre-prandial testing thing, as I didn't even learn about that method of blood sugar control until March, although I think it is quite a common way to treat diabetes. My learning to do tight control was in pregnancy, where they only cared about post-prandial numbers even if you were taking insulin. I would chase meals with extra humalog if my values were too high, and then up the next days dose based on the previous day's high. Insulin needs are constantly changing in pregnancy. When I used to live in not such a small town, I would keep all my insulin supplies in the same case as my testing supplies, and it all just went with me everywhere. Perhaps something like that would help you. > And no matter how much easier it gets, it will never be knowing I can > just grab a burger and throw out the bun and assume that's OK. Why not? Just like before you took insulin that burger is not going to raise your blood glucose. > I know T1s who had previously been on mixed insulins find the basal/ > bolus routine very freeing. But going the other way, from not needing > insulin at all to basal/bolus, feels very restrictive. You know I can relate. It's been over 7 years since I went from just basal insulin and low carb to basal, bolus. It did feel really restrictive at first now that you mention it. It was during my first pregnancy, and I dind't think it was going to be lifelong. I thought I could quit it after the pregnancy, but that didn't work out for me. So, I am sorry that you are going through this right now. You're right. It's no fun. But if you're anything like me, you will get so used to it that you will forget it was ever hard, like I just did. KC > I take Humalog also, but that's exactly why I feel I can't "just > eat". I have to know my preprandial and the amount of carb and > protein to figure the Humalog dose, and then set a timer to test the > postprandials. Do you adjust humalog for protein as well as carbs? I only take mine according to carbs. And, I no longer use a sliding scale based on my BG. (though I would probably take some extra if I were very high... but that would be if I had an infection, and then I'd have a different carb ratio as well as correcting afterwards as needed.) If I don't have an infection, I actually get fairly tight control with very little insulin. I also don't always test. (most of the time I do, but If I'm caught up at work with customers etc. I can't get away for a pp, and if I just don't feel like it sometimes, I'll skip on the testing. I do test if I'm feeling high or low though). > This is not the same thing as before insulin, where I knew if I ate > right, my bg was almost certainly OK. [quoted text clipped - 5 lines] > expected and you get hungry and realize... I don't have insulin, I > can't just stop and pick something up. I use the novolog pen, and I have a place where it fits right on my meter case, so if I have my meter, I have my insulin. (now though I'm on the novo-pen Jr. and it has it's own case, but I usually take it with me along with my meter whenever I go. There is a slot in the insulin case for another pen, and I stick my levemir there.) Of course, I wound up working a split shift today, and in my hurry to leave from the first half of my shift, I left my meter and insulin at work. So, I very low-carbed lunch. (swiss cheese wrapped around pickles turkey and mustard). And I ate dinner right before going to work, and injected as soon as I got there. > I *know* the whole insulin thing will become second nature with time, > just as low-carbing had. But it hasn't yet and I need to really think > about what I'm doing. How long have you been on insulin? I've been on it since March, and it more or less is just a part of what I do now. I like the flexibility I have in eating with it, I don't have to give up my favorite foods. I still have to think more about food/eating than I would like, but I know I *COULD* eat whatever I want without spiking as long as I inject. > And no matter how much easier it gets, it will never be knowing I can > just grab a burger and throw out the bun and assume that's OK. Ah, but with the humalog, you have the freedom not to throw out the bun! > I know T1s who had previously been on mixed insulins find the basal/ > bolus routine very freeing. But going the other way, from not needing > insulin at all to basal/bolus, feels very restrictive. I hear what you are saying. I like the basal/bolus routine for it's flexibility, but it would sure be nice not to have to inject at all. I think however, I would not like the restrictions I would have with oral meds/diet exercise. However, there is question as to how well those would work for me anyways. I can't take the sulfonylureas (or however that is spelled) because I'm allergic, and my doc honestly has no idea how IR or not I am. (with the low doses of insulin I'm on, it's probably not much if at all.) Just out of curiosity, what is your basal dose of insulin, and what is your carb ratio? If you inject for protein as well, what is that ratio? Emily > Do you adjust humalog for protein as well as carbs? I only take mine > according to carbs. And, I no longer use a sliding scale based on my BG. > (though I would probably take some extra if I were very high... but that > would be if I had an infection, and then I'd have a different carb ratio > as well as correcting afterwards as needed.) It depends on the meal. I can ignore carb if it's under 10g per meal and can ignore protein if it's under 30g/meal. > If I don't have an infection, I actually get fairly tight control with > very little insulin. I also don't always test. (most of the time I do, > but If I'm caught up at work with customers etc. I can't get away for a > pp, and if I just don't feel like it sometimes, I'll skip on the > testing. I do test if I'm feeling high or low though). Yup, I find the same. I can get *much* tighter control than I had for a long time. Prior to my bg going wonky subsequent to the pancreasitis, I was lucky to keep fasting under 140. My postprandials stayed under 140 too. But that was the best I could do, NOTHING would get my fasting down. Now it's pretty easy to have my fasting under 100 and nearly all postprandials under 120 with most close to 100. > I use the novolog pen, and I have a place where it fits right on my > meter case, so if I have my meter, I have my insulin. (now though I'm on > the novo-pen Jr. and it has it's own case, but I usually take it with me > along with my meter whenever I go. There is a slot in the insulin case > for another pen, and I stick my levemir there.) I need a different case. My meter is in one case, my insulins (Lantus vial, Humalog pen, syringes and pen tips) in a second case, and I carry the Sweetarts separately. I need something that holds all of this stuff in one case. > How long have you been on insulin? I've been on it since March, and it > more or less is just a part of what I do now. I like the flexibility I > have in eating with it, I don't have to give up my favorite foods. I > still have to think more about food/eating than I would like, but I know > I *COULD* eat whatever I want without spiking as long as I inject. I've been on insulin since May, but the first few weeks, I was hospitalized and don't know how much I was getting or what my bg readings were as I was stoned. Only thing I know is I was eating low carb cause I insisted on that. So I only have data for June and July. I don't have any idea what the ideal amount of carb is on insulin and I did think about that. What I know is, before I lost control and needed insulin, I controlled my bg at around 50g carb/day. So I'm kinda doing the same thing now as I'm used to eating that way. > > And no matter how much easier it gets, it will never be knowing I can > > just grab a burger and throw out the bun and assume that's OK. > > Ah, but with the humalog, you have the freedom not to throw out the bun! I don't eat more than 30g carb at a meal hardly ever, so I don't really adjust for carbs that directly. So... I don't eat the bun and just adjust via insulin because I don't want to take more insulin. I think it's healthiest to take as little as I can get away with. What I *have* done is after going low and correcting with Sweetarts, if I'm still lowish at my next preprandial, I then decide it's a meal that can "afford" something like a burger bun after all. I also don't take any Humalog if I've previously gone low. So... if I'm eating a burger bun, I'm doing it without a bolus at all. ;) That circumstance is kind of rare though. It's happened twice so far, and I assume it's cause I'm still adjusting to insulin... my dosages are still going down. > I hear what you are saying. I like the basal/bolus routine for it's > flexibility, but it would sure be nice not to have to inject at all. I [quoted text clipped - 4 lines] > how IR or not I am. (with the low doses of insulin I'm on, it's probably > not much if at all.) I was already accustomed to a very low-carb diet, so that doesn't seem restrictive to me. It's how I'd been eating for years. Exercise is pretty much non-existent at this point since I'm recovering from the surgeries and on narcotics still. I have pain and very little energy. I expect once I'm healed up and can do more, I'll have to lower my basal further. > Just out of curiosity, what is your basal dose of insulin, and what is > your carb ratio? If you inject for protein as well, what is that ratio? I just decreased my Lantus from 30 units -> 25 units the other day and do not seem to have lost any control at all. I currently dose my bolus by asking these questions: Is my preprandial over 100? Is it breakfast? Is the meal going to contain more than 10g carb? Is the meal going to contain more than 30g protein? If all of the above are false, I take no Humalog. If one is true, I take 3 units. If two or three are true, I take 6 units. If all four are true, I take 8 units. The only rule the doctors gave me was the preprandial one, I figured the rest out via trial-and-error and lots of testing. I don't suggest these rules for anyone else, it's just what I have found works for me to keep my postprandials in my goal range. My doctor's goal range for me was 80-200, so I've been figuring this stuff out myself as I wasn't fond of his goals. So... from discharge I was on 40-45 units Lantus and am now on 25. And my bolus was 10-12 units and now is 3-8. Pretty much, my insulin has been cut in half. I snipped this all as it was getting long. It sounds like you are doing a good job of changing your insulin as needed. I too did that. I had sort of been 'taught' how to do that in the diabetes education classes I went to, so I had no problems lowering my doses myself (or raising them if needed, but that wasn't the case). I started on 10 units of levemir at night, and eventually went down to 3 units. However, when my morning readings were between 110-130, I increased that up to 5 units. (my goal is to be 80-110 pre meals and morning fasting--that's the AACE goals). I'm also to be 90-140 post meals and bedtime. Now that my UTI is FINALLY gone, I'm down to 4 units levemir at night. With the novolog, I was terrified of hypos (especially at work where I am quite active much of the time) so I always rounded down with what I ate on the carb counts. I found I was in a good range with one unit at 25g of carbs (I was started on a 1:15carb ratio at first). So I ate 30g of carbs, and only used one unit, worked pretty well. So I came upon the 1:30 carb ratio. As to how I dealt with 45g carbs, it depended on how active I would be, time of day etc. Now I have the novopen JR. and can just do a 1.5 unit bolus for 45g carbs. I was low carbing severely when I was going out of control without meds after diagnosis, but before blood tests were in to say if I was type one or type two. The NP wanted to wait until all tests were in before putting me on meds. Well, I was staying in the 200-400range and sometimes going up to 500. This was with low carbing--no more than 15g at a meal,so about 45g a day. (I think I had a sinus infection at the time, maybe so that would have explained some of it, my insulin use triples when I have an infection). It was the endo who sees me for my thyroid (same clinic, he sees me half the time for my thyroid/diabetes the NP sees me the rest of the time) that decided I should be on insulin ASAP. He felt I was heading towards a coma if my BG's didn't come down. At first, the 10units and 1:15 carb ratio seemed o.k., but as time went on I had to adjust down majorly. It's also possible that I had been high for so long (at least above 200 for around a month) that beta cells were losing function, and as I regained BG control, they healed, causing me to need less insulin. Dunno. (I do know that my c-peptide, done before my sugars spiked so high, showed I make in the middle range of what a normal person does.) I find it interesting that you adjust for protein as well. Kinda makes sense, but I can get away without a bolus if I have less than 15g carbs at a time. (I suppose that is usually a snack, and I'm not likely to have a lot of anything at a snack, however, I find if I have a very low carb meal--say just my goulash and green beans, or just an omelet with cheese and low carb veggies one unit of novolog is too much, and I don't spike too high without any. I do go above the 110 I'm used to post meal, but I don't go above the 140 which is the upper limit of my goal range). I can't take less than one unit of novolog, even the novopen JR. starts at one unit, and then goes up in half unit doses from there. Is your doctor an endocrinologist? If not, I suggest getting a referral to one. Most endocrinologists go by the stricter AACE guidelines which are (as I mentioned earlier) 80-110 fasting and pre-meal, 90-140 post meal and bedtime. They definitely think 200 is WAY too high. Also, I'm officially hypo at 67, but if I'm below 80 it means I need to eat. (just not 15g fast acting carbs to bring me up from a hypo--but only the snack). I've been eating my trail mix regularly at work these days. I often don't get to lunch until 1:30 (I come in at 7:00), so I'll have a bit of the trail mix around 11:30 or 12:00 and it gets me through until lunch. You do have an interesting method for calculating insulin use at meal times. I still have to inject, even if I just treated a hypo (at least usually). I don't count the carbs used for treating the hypo, but I do count the carbs in the meal. If I don't I'll likely get a liver dump on top of the meal and go high. (I actually tend to run high much of the day after having a hypo (depends on the severity of it, the lower I go with the hypo the more likely I am to run high. The opposite of my bi-polar, where the higher my mania the lower my crash afterwards). I think my body just liver dumps to prevent hypos and I therefore run high. Dunno for sure. Emily > I snipped this all as it was getting long. Me too. ;) When I was in the hospital, I had a PILE of doctors. About 6 different people from the cardiologist's group, 5 different doctors from the internist's group, one endo and the one surgeon. They told me afterwards I needed to make follow-up appointments with the cardiologist, the surgeon and either the internist or the endo. Well, I had been less than impressed with the endo, so I went with the internist. Had the endo been like yours, I'd damned well have wanted her instead. But... she wasn't, so I figured to try the internist. The specific doctor I got assigned to me from the internist group is OK. He listens to me and we make decisions mutually, with me taking the lead on diabetes and him on everything else. I'm relatively content with him, though yes his "goals" for my treatment are ridiculously lax, but he doesn't oppose me having tighter goals, so that's kewl. I tend to run low after a hypo; and conversely, if I get a high reading, I tend to stay high for a day or so. It seems as if my bg is very inertial, so I've kinda learned not to adjust my overall rules until I see what is happening for several days in a row. Like you, I've discovered some things outside of the rules they gave me. For instance, they consider below 80 a hypo whereas I discovered I can go to 70s and just stay there indefinitely, it's not a hypo and has no symptoms and doesn't keep going down, so doesn't need correction. And while I called them the first time I adjusted insulin outside of the range they gave me, since then I just use my best judgment, which they're cool with/ I think diabetics have to take their treatment into their own hands to a very large degree; no one can ever be as expert at what works to controls my bg as me. It sounds like you've done a good job of working out what works best for you also. Depression though is tough, and for me, that's where my ability to control my diabetes gets rough. It's very difficult to give a damn about what I'm eating and how much bolus I need when depressed. I have kinda learned how to talk to myself about it though. We've got it relatively easy in terms of the figuring it out part of things; those folks who pump have REALLY complex stuff to figure... different boluses at different times of day, etc. >> I snipped this all as it was getting long. > [quoted text clipped - 5 lines] > me afterwards I needed to make follow-up appointments with the > cardiologist, the surgeon and either the internist or the endo. Wow, that's a lot of doctors! I don't think I even had that many when I was septic and in the ICU. > Well, I had been less than impressed with the endo, so I went with the > internist. Had the endo been like yours, I'd damned well have wanted > her instead. But... she wasn't, so I figured to try the internist. Yeah, if the only person I had met from the endo clinic I go to was the NP I first saw (who wanted to wait for test results before medicating me even though my BG's were 200-400 and even going to 500+ occasionally... I'd have not been impressed either. Perhaps you could get a referral to a different endo. > The specific doctor I got assigned to me from the internist group is > OK. He listens to me and we make decisions mutually, with me taking > the lead on diabetes and him on everything else. I'm relatively > content with him, though yes his "goals" for my treatment are > ridiculously lax, but he doesn't oppose me having tighter goals, so > that's kewl. Well, if you and the internist are managing o.k., I guess that is fine. If it gets into territory where neither you nor he know what to do, then I'd recommend an endo, but right now, since he lets you take the lead in diabetes care, it sounds like you are doing just fine. > I tend to run low after a hypo; and conversely, if I get a high > reading, I tend to stay high for a day or so. It seems as if my bg is > very inertial, so I've kinda learned not to adjust my overall rules > until I see what is happening for several days in a row. When my BG goes unusually high, I know I'm in for a few days of high--unless I increase the insulin. (I also know that either a)my menstrual cycle is about to start or b)I've got an infection somewhere). If I go low, then I'm high the rest of the day also. Generally. If I've just gotten over an infection though, then I may have overdone the levemir, or am overdoing the novolog in which case I have to adjust to get my BG back to a normal range after eating. > Like you, I've discovered some things outside of the rules they gave > me. For instance, they consider below 80 a hypo whereas I discovered [quoted text clipped - 3 lines] > outside of the range they gave me, since then I just use my best > judgment, which they're cool with/ With me, if I'm below 80, I could be headed for a hypo. It basically means it's time to eat--either a snack or a meal, whatever is on the schedule. I do feel it when I go below 80 as well. I think sometimes it depends on how long I wait to test--i.e. if I get caught by customers etc., if I test right away, I may only be in the 70's and just need lunch or a snack, if I test later, I may be hypo. I have always just adjusted insulin on my own. I got some info on how to do that at the education classes, and just kind of went with it. At my first endo apt. after starting insulin (three days after actually)my doc told me I may need to adjust down my levemir. So, I went with that and did. He also said I might need to split the dose into a morning and night dose. Didn't really then, only split it now if I've got an infection or hormones are messing with me. Otherwise, my night numbers are good without dose splitting. I'd rather not do five or more shots a day. Keeping it to four (unless I have carby snacks) is better. > I think diabetics have to take their treatment into their own hands to > a very large degree; no one can ever be as expert at what works to > controls my bg as me. It sounds like you've done a good job of > working out what works best for you also. Actually, I've had a couple of CDE's tell me that the goal for diabetics on insulin is exactly that. To be able to adjust their insulin as needed without having to call someone to figure out how to adjust it. With that info, I have been adjusting my own insulin as I need to. I figure I test often enough that if I've taken too much, I'll find out and treat the hypo, if I've taken too little, I'll take some more and correct. > Depression though is tough, and for me, that's where my ability to > control my diabetes gets rough. It's very difficult to give a damn > about what I'm eating and how much bolus I need when depressed. I > have kinda learned how to talk to myself about it though. Yeah, I hear you on the depression. My doc gave me permission to slack off on testing as long as I don't slack off on insulin. Well, prior to going into the hospital, I had kind of stopped both. Also, when depressed I used to eat nothing but cereal. That doesn't work so well now, especially if I'm not injecting. My depression is better though--I even went manic, and now I think I'm in the happy middle ground. I hope I don't crash from having gone manic, but I don't see any signs of it right now. > We've got it relatively easy in terms of the figuring it out part of > things; those folks who pump have REALLY complex stuff to figure... > different boluses at different times of day, etc. Hmm... I guess I kind of figured once a pumper figured out what worked, then they programmed the pump and it did all the work. They could override it for like say the pizza effect, or if they were sick, but in general the pump would put out the right doses at the right times after being programmed. Of course, a pumper could program the pump to put out insulin exactly as we do, but that would defeat the purpose of a pump. I know most people get far tighter control with a pump, so it must have it's advantages. My cousin's girlfriend is a pumper, has been since they were first available, and she does quite well with it. If I were making no insulin of my own, I'd like to be on a pump. I couldn't ever afford one, as my insurance has a $1,000 deductible for a pump and then I'd have to pay 20% of the cost after that too. But, I kind of thought that if I became depressed and didn't want to inject insulin, if I had the pump in me, then it would do it for me and I'd still be getting insulin. (I know the tubing etc. has to be changed about every three days, but hopefully I could manage that.) Emily > jackiepa...@gmail.com wrote: > > When I was in the hospital, I had a PILE of doctors. About 6 [quoted text clipped - 5 lines] > Wow, that's a lot of doctors! I don't think I even had that many when I > was septic and in the ICU. I was in nearly two weeks, so I had different people wandering in-and- out. I guess the physician groups take turns doing rounds. > Yeah, if the only person I had met from the endo clinic I go to was the > NP I first saw (who wanted to wait for test results before medicating me > even though my BG's were 200-400 and even going to 500+ occasionally... > I'd have not been impressed either. Perhaps you could get a referral to > a different endo. That's just ridiculous. Doesn't matter what kind of diabetes you have, if you have readings like that, you need insulin. Even if the need turns out to be temporary, you need it THEN. > When my BG goes unusually high, I know I'm in for a few days of > high--unless I increase the insulin. (I also know that either a)my [quoted text clipped - 3 lines] > overdone the levemir, or am overdoing the novolog in which case I have > to adjust to get my BG back to a normal range after eating. I'm trying NOT to increase the insulin when I'm a bit high, but let it ride and see if it comes down in a day or two. I was talking with a long-term T1 on a web forum and he says when he corrects for high insulin, it seems to creep up over time, and he can find himself taking as much as 40% more insulin than he normally needs. I'm kind of taking that advice to heart, so mostly ignoring it if I'm a bit high. Not... like if I'm sick, I know I have to adjust temporarily then. But if I'm just 10-20 points high, I wait and see if it comes down before adjusting the insulin up. I think our bodies can adjust to some range of insulin and I'd rather keep mine on the low side, for a lot of reasons. > With me, if I'm below 80, I could be headed for a hypo. It basically > means it's time to eat--either a snack or a meal, whatever is on the > schedule. I do feel it when I go below 80 as well. I think sometimes > it depends on how long I wait to test--i.e. if I get caught by customers > etc., if I test right away, I may only be in the 70's and just need > lunch or a snack, if I test later, I may be hypo. Yeah, I can see why the rule is under 80. But for me... if I get a postprandial in the 70s... my next preprandial is in the 70s too. I don't have symptoms of a hypo in the 70s either, not even hunger particularly. So it doesn't seem to mean a hypo for me. > Actually, I've had a couple of CDE's tell me that the goal for diabetics > on insulin is exactly that. To be able to adjust their insulin as needed > without having to call someone to figure out how to adjust it. With > that info, I have been adjusting my own insulin as I need to. I figure I > test often enough that if I've taken too much, I'll find out and treat > the hypo, if I've taken too little, I'll take some more and correct. Sounds to me like you've been lucky with both your endo and CDE. > > Depression though is tough, and for me, that's where my ability to > > control my diabetes gets rough. It's very difficult to give a damn [quoted text clipped - 9 lines] > I don't crash from having gone manic, but I don't see any signs of it > right now. for me, blowing off the diet and insulin is almost a half-hearted suicide attempt; like I'm wanting to do something *extreme* but not actually fatal. But... being alive and in worse health is not gonna help anything. If I *really* want to kill myself, I'll just freaking DO that, not mess around with my health in this half-assed manner. So for me, I've been reminding myself that if I'm depressed, I can bloody well be depressed and take care of my diabetes anyways. So... that's what I tell myself when I'm depressed. I'm gonna be depressed whether I take care of myself or not, so might as well take care of myself. > > We've got it relatively easy in terms of the figuring it out part of > > things; those folks who pump have REALLY complex stuff to figure... [quoted text clipped - 9 lines] > it's advantages. My cousin's girlfriend is a pumper, has been since > they were first available, and she does quite well with it. I absolutely think it has advantages, but it seems a LOT more complicated than a regular basal/bolus routine in terms of how much you need to understand. >> jackiepa...@gmail.com wrote: >>> When I was in the hospital, I had a PILE of doctors. About 6 [quoted text clipped - 7 lines] > I was in nearly two weeks, so I had different people wandering in-and- > out. I guess the physician groups take turns doing rounds. Oh, yeah, then I guess there would be many docs. Specialists may only work four days a week, and there would be others from the practice covering. I probably had as many docs when I was septic when I was four. I don't remember my dad visiting me at all, but my mom said he came daily. He probably was wearing his doctor 'uniform' so I just didn't separate him from all the other docs in to see me. >> Yeah, if the only person I had met from the endo clinic I go to was the >> NP I first saw (who wanted to wait for test results before medicating me [quoted text clipped - 5 lines] > have, if you have readings like that, you need insulin. Even if the > need turns out to be temporary, you need it THEN. That's what the CDE thought, and I finally did get insulin. I was almost just put on oral meds, but then the endo that does my thyroid decided that I needed insulin instead. We hadn't done all available blood tests at the time, and he still wasn't convinced I was type two. (he still hasn't decided any of that really, but I am staying on the insulin cause it works). >> When my BG goes unusually high, I know I'm in for a few days of >> high--unless I increase the insulin. (I also know that either a)my [quoted text clipped - 16 lines] > temporarily then. But if I'm just 10-20 points high, I wait and see > if it comes down before adjusting the insulin up. Ah, I'm not talking 10-20points high. (I can be 10-20points above normal PP and still be in range, since I don't usually go over 110 pp). I'm talking getting into the 200's. Then I do bring it down. I also don't go that high for no reason--it's either hormones or an infection. I was taking at least three times my usual insulin with my last infection! > I think our bodies can adjust to some range of insulin and I'd rather > keep mine on the low side, for a lot of reasons. Yes, I agree. I do keep my insulin use as low as possible. Of course, I use so little as it is. I didn't realize how tiny one unit of insulin is until I was on the p-ward. I didn't have my pen there--instead they drew the insulin into a syringe from a vial. One unit is incredibly tiny! I used more novolog there than usual(cause of the high carb ADA diet I was on) and still only used about ten units of novolog a day. I also was using three units of levemir at that time. Shortly after, it crept up to five. But, I think I can probably go back down to three, |
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