Wednesday, November 12, 2008

Our crazy ER visit

I'm sitting here awaiting the next hourly blood sugar check for Maddison. The last 15hours have been total hell both physically and emotionally. The chaos of today started as any other morning. Maddison was complaining of a stomach ache, and since we had off school yesterday for Veterans Day, I knew she would be sad to go back to school. I figured she had a stress tummy ache. She whined ALOT. Lately she has gone to school without complaint so I did feel this could actually be a real stomach ache as much as she whined and moaned. She cries wolf alot to try and stay home from school and I wasn't entirely convinced, now I feel horribly guilty for sending her to school.

Maddison wouldn't get out of the car when we parked in the school parking lot. I was going to walk her in and check her blood sugar as always. She pleaded with me to believe her. Her BS was 62. Great I thought, now I really think she might be for real with this stomach pain. I decided to sit around in the nurses office and see this low rise instead of leaving it up to them and heading off to work. She went up to just 78, then 72, then 90. I'm now very late for work and I assure Maddison she can make it through the day although I really feel I should trust her and the way she is acting. She does look pale, but, she often does after being low of course! She heads off down the hallway to class and I just don't feel right about this. I guess you should always trust your parental intuition. I decided to stop for coffee before heading on my way to work in case the nurse's office calls and she is actually sick or continuing to be low. After stalling around getting some much needed coffee I start the 30 mile drive to work. I'm not even half way to work and my cell phone rings. Surprise! Maddison really is sick this time, and up came her breakfast as sooon as she got to class! Now I am turning around heading back to school and praying her BS stays in safe range. Talk about feeling guilty!

Maddison's blood sugar was between 60-90 over the next hour, with no breakfast carbs left to digest. Ketones are still clear on the blood ketone meter at .3 but the scariest issue is that she has alot of active insulin from her breakfast bolus. She will drink gatorade and regular Sprite but can't keep it down. I decide I am going to have to use some mini doses of Glucagon to boost her blood sugars. I called her Endo for dosing instructions. 15u of glucagon later she is 208. She continued to vomit at least every hour and her blood sugar would go up for only a short time and then drop back down again. A few hours later I had to double the glucagon as directed and ketones were now at 1.8 (zero is normal, over 1.5 you are at risk of DKA) and blood sugar is low 300's. Completely exhausted, Maddison falls asleep while I watch over her like a hawk knowing her blood sugar isn't going to stay at 300. 30 min later she wakes up to vomit and she is 108. Holy fast drop! Ketones are now 2.2 and I call the Endo back assuming we will be sent to the ER for some D5 and an insulin drip to stop the ketones and avoid DKA. Amazing how fast vomiting can become an emergency for Diabetics.

We arrived at Children's ER and the triage nurse is taking her sweet time, so I blurt out that Maddison has high ketones, vomiting and high blood sugar (even though she is now 152) Mentioning this puts the nurse into faster action thank goodness! I have to say, I am so excited about a new medication device for numbing IV sites in children. It is called the "J tip" and it is a Lidocaine (or something like that) air forced container that you place over the skin on the site to be numbed. Press a button, hear a loud SWISH and the numbing medication is instantly forced through your skin! WOW! Maddison didn't feel a thing when they started her IV. As always she was amazingly strong and brave. I'm so happy they have this new device for kids!

The staff is very nice, labs are quickly sent to rule out DKA. They check her blood sugar with one of the hospitals ancient meters that require a ridiculous amount of blood.....BS is good at 132. Bolus of Saline fluids is given with anti-nausea medication. Maddison feel so much better within the hour. Negative DKA. Her vomiting never came back. The craziness is this..... of the six hours we spent in the ER not once did they check her blood sugar again. Not once did they re-check her ketones. I continued all her Diabetes care checking both sugars and ketones every hour. Her blood sugar was stable in the 90-120 range but her ketones increased to 2.4 by the time they were planning to discharge us. The Endo came in to speak with us and assured me the high ketones were from dehydration, not from uncontrolled Diabetes. Um, yeah. I get that. I continued to ask him why we shouldn't be concerned that she still has high ketones after the multiple fluid boluses. I was instructed to stop checking ketones because it will just cause worry. I was told this is dehydration, not DKA....Um yeah....I get that too! But at what point do I need to worry that her ketones have been high for 10 hours!!? I can't give insulin to rid the ketones because her BS is low. She cant eat and her blood sugar is not budging with sugar fluids. I understand we have the ketones because the dehydration and illness, but I have always done alot of reading to prepare myself for the day Maddison has a vomiting and high ketones. From all my past studies, I really felt we needed dextrose IV with insulin before sending her home. I have listened to alot of parents horror stories of how quickly you go from no DKA to DKA so I assume this is where we could be headed if we cannot get rid of the ketones quicker! I know, I am not the Endo and I need to trust his knowledge, but I just felt nervous taking her home with high ketones.

Upon discharge I just couldn't stop my questions. I was nervous and an emotional mess at this point since I have never dealt with lows and ketones at the same time. I wanted to know why they didn't check her blood sugar, they said because normally they only do every 4 hours or so! I asked why they didn't recheck her ketones to make sure they didn't rise, they said because they already know she isn't in DKA. So my rational mind is thinking, ok...they treated the vomiting and dehydration and that was it. I was left to care for all the Diabetes management, which I am happy for and I appreciate.... BUT, what if her blood sugar was now HI and her ketones increase alot? They would have no idea because they never checked! I told the ER doctor how sad and scared that makes me. I explained why I was so confused with their care plan and they assured me she is fine with high ketones!!?? They had no interest in her Diabetes once she was cleared of DKA. I asked why they didn't want to know her BS before we went home, the ER doctor responded with, well lets re-check her blood sugar then before you go home. Oh, how nice of them! We were discharged home with instructions for managing Gastroenteritis. Nothing was mentioned about Diabetes! I wanted to know what to watch for as far as her Diabetes (even though I already know) I just felt SOMEONE should give me direction as far as how long are the high ketones "ok" and what the hell is the plan to keep blood sugar up (since it isn't going up regardless of anything!) Finally, they were irritated enough with all my questions and second guessing that they called the ENDO back. If blood sugar is over 250 and she vomits or appears to worsen we should return. Oh, gee....thanks. I left the ER feeling completely unsure of our entire experience.

I really am trying to make this as short as possible...Within an hour of getting home Maddison had some crackers. No bolus, (yes I know she needs insulin!) her blood sugar just wont rise enough to bolus yet. Her liver is depleted from all the vomiting and glucagon so we can't chance her going low over night. Now a fever sets in at 101.5 and she falls asleep. She finally hits 212 so I correct that with half the suggested to see what happens. I check her ketones and they are now 3.0!! AHH! So, I give the full correction and hoover over her as she sleeps. Luckily, her blood sugar stayed stable in the 120's all night and ketones dropped to 1.1 within the hour thanks to being able to give her insulin for the crackers!

Yesterday we still battled lows and high ketones. She feels great otherwise. She even helped me all day out in the yard. I know it will just take some time to get back on track. She isn't absorbing any carbs until hours after eating, so at this point all I can do is correct the high which will then clear the ketones. It has been a long couple of days to say the least!

I know we all have our own stories about ENDO's, ER visits, hospital stays and
fighting illness with Diabetes, each very crazy in it's own way. I really doubted the decision to send us home with high ketones (I read to much about Diabetes!) but of course we were just fine. At the time I was convinced we would be added to the list of ER horror stories and end up back there in DKA within hours because the ketones that lingered. Our crazy visit actually made ME look a bit crazy for being overly doubtful of their treatment plan. I was sure I knew what was best for Maddison. All I have learned about ketones, vomiting and children with Diabetes was completely opposite once we entered that ER. All they seemed to care about was ruling out DKA, which I do understand. But WHAT if I was a mom that wasn't checking blood sugar and ketones during our hospital stay? What if we got home to HI blood sugar and ketones off the chart? What if Maddison took a turn for the worse? We would have had to return and make another 40 min drive to start all over. I just wonder WHY they dont watch blood sugar and ketones during the ER stay. I just don't get it. Overall we had great care and I appreciate them tolerating all my questions. I didn't learn anything except to trust the ENDO :) Hopefully we wont have to doubt them ever again.


Scott K. Johnson said...

Holy smokes! What a ride.

I would think they would be ALL OVER BG's and Ketones?

Lynnea said...

O.K...reading this freaked me out!!! J.J. has yet to be sick WITH ANYTHING in almost a year with diabetes. I'm going to freak the first time he gets a stomach bug! I need your phone you can calm me down:-).

As far as hospital visits with diabetes...they don't manage it...another caregiver has to, or the person themselves. I've heard this repeatedly. Really stinks considering your at a hospital..they should be all over it.:-(

Penny Ratzlaff said...

Apathy. It's called apathy. I work in health care and unfortunatly I see a lot of it.

I'm glad Maddison is doing better. What a scary experience!