School and Lows...WWYD?

I'm going to preface this with, we don't have the best relationship with the school, so I am very careful in how I speak to them and they are very restricted on what they are and aren't allowed to do when it comes to DS' pump.

Today, after lunch and recess (they are back to back), he went to the nurse's office because he felt low. They tested and he was 64. I just sent in glucose tabs, however, they didn't make it to the nurse's office, they were still in his backpack, which was in his classroom. She called me and we agreed to give him 4 oz of OJ and that the aide would follow him back to class once his number was above 80 and get the tabs. That was at 1:50. At 2:30, she called me back and said that at 2:10 he was 63, so he dropped 1 point, and they gave him another 2 ounces of OJ and retested and he was now 68. At this point, the aide had gone to his classroom and gotten the glucose tabs. I asked her if they had tested him on his secondary meter, just to be certain, because we've had repeat lows, but not 3 in a row. She put me on hold and they tested him and it matched the Ping remote exactly at 68. I told her, give him 4 and retest him in 20 minutes. Keep in mind, at this point, he's been in the nurse's office for over an hour, the last hour of school, which is science/social studies time (so learning time, not play time). She called me back and he was 72. I told her, I really don't want you giving him anything else, because it's all going to hit at one time and then we're going to deal with a rebound high that's a pain to bring down. She agreed to wait 10 more minutes and retest. After the 10 minutes, he was 87. He was sent to extended day and I've been in contact with the extended day director just letting her know to keep an eye on him and call me if she needs anything.

If he was home, I would have followed the same protocol; however, it feels like the nurse was aggravated with me because his sugar wouldn't come up. I'm also concerned about the hour of instructional time, but I will address that with the school because these things happen. This nurse is an RN, and I know they don't get a lot of training on Type 1 diabetes, but when things like this happen, I feel like she has learned nothing that we've talked about. I'm not looking to raise heck with anyone, I just need to know a better way to respond to her when this happens. They kept telling me how much insulin he had on board, and I finally had to tell her even if she suspended his pump right now, it's not going to raise his numbers right this minute, that takes time too.

So I guess all this to say, how would your school nurse handle that? I do work at home, and I do have the flexibility to be around to do more things, but I just didn't feel this was an instance that warranted jumping in the car and checking him out. Thoughts?

 

I'm guess I'm trying to figure out what you wanted her to do differently? She called with a low and you came up with a treatment plan. He didn't come up, so you came up with another treatment plan. She retested, per your request, on the other meter, and treated. How could she have prevented the loss of instructional time if you've said to stay in the clinic until he comes up, which he didn't?

 

I'm sorry, I wasn't clear. I'm not upset with anyone about the loss of instructional time. I'm upset because I feel like she was aggravated with my treatment plan. Like she wanted me to just come and get him and take him off her hands. And also like she is questioning the treatment we use. I didn't want him loaded with more carbs and she wanted to give him something else, yet by waiting that extra 10 minutes with nothing, he came up. I just am looking for what others nurse's would have done in this situation?

 

I can see where she is coming from, even though it's not ideal. She wanted instant gratification. Meaning, load with carbs right then and there so that BG was pushed back up and he can go back to class, and so that he possibly wouldn't fall through the cracks if the office got busy. This way, there was little error for him being forgotten about and not retested.

My daughter is of the age now where she treats herself, but if it's a stubborn low, she goes to the nurse and they work on it together. Usually, it means having more carbs than she normally would in my presence. But, while it's not ideal to carb load like that, I'm ok with it if it makes my daughter feel more comfortable.

 

Did she actually suggest you come get him or verbally question your directions?

 

I think tone is everything in these situations. But that being said, we have a very good relationship with our school, and I have had countless identical conversations with the nurse over the years.

 

My perspective may be skewed by our kid's younger age (DD is just shy of 4). She attends full-day preschool without a nurse on staff, so we work with the teacher over the phone. The preschool is great, but they have suggested we pick her up in this sort of circumstance, which felt like a reasonable request. We've experienced triple lows several times -- sometimes before onset of a stomach bug, and on other occasions probably connected with another health issue DD suffers (celiac, undiagnosed until just recently). The untreatable lows scare the heck out of me, and we almost always call our endo by the third low reading -- admittedly, we don't yet feel like seasoned veterans like some of the other posters here, and we may be overly cautious. On one occasion, we had a 2-hour-long quadruple low for no explicable reason, and endo instructed us to administer low-dose-glucagon, which worked like a charm.

This is all to say, I see how it's aggravating to get so many calls from the nurse, but the experience of treating a low that won't come up probably feels very stressful to the nurse with the kid sitting in her office. Hopefully this is just a fluke that won't happen again. If you do see another triple low in the next day or so, you might keep your antenna up for a developing bug and check in with the doc?

 

I haven't learned how to multi-quote, so please bear with me.

We, at one point, did allow her to give more carbs when he was low, but after the 3rd time of them giving him 6 oz of apple juice and his number being over 250 an hour later, we had to change that. We now strictly follow the protocol on his DMMP, so that there is no questions. If he was home, I would have followed the same thing I was asking her to do. As a matter of fact, at 1:30 am Sunday, we had a double low and I dealt with it the same way.

She did not come out and ask me to come get him, but she did question what I asked her to do all three times she called. I don't mind the phone calls, they are following what has been set in place, and I never, ever complain about getting them. Believe me, there have been days where I've received 9 calls from the school, and I've answered and addressed each one. The tone in today's call was that of, why can't YOU just come get him and deal with this, that's all.

And he was low again at 5pm. I got the call from Extended day. I was already putting on my shoes to go get him, so I just had them give him 4 glucose tabs and I was there before time to recheck.

I guess it's a catch-22 almost. I dont really want him carb loaded because his rebound highs are a brat to get down, but I can't always just drop my work and go take care of him (in an emergency situation, absolutely).

As for double/triple lows: we see them at least twice a week. We've tweaked his numbers, but because of his schedule at school, it's hard to get them just right. They don't do 9 weeks of PE, 9 weeks of computer, 9 weeks of art, they do 2 weeks PE, then lunch, then recess, 2 weeks art, then lunch, then recess..and the weeks he has PE, then lunch, then recess, we adjust his basal, and we've prevented the really low lows we were seeing (high 30s, lows 40s), but haven't completely gotten rid of them.

 

I agree that tone can make a big difference in these circumstances. However, given that she followed your instructions and care plan, perhaps you can just overlook your issue with her tone of voice? She may have been repeating or asking about the instructions just to clarify them or for the benefit of the aide or she may have been asking because she was annoyed...but if you can overlook the tone and focus on the end result, that might help.

As much as I hate to over treat a low, I am more inclined to more aggressively treat a low that is slow to respond when DD is away from us.

 

I'm sure you think I'm being hard on you - but I honestly think that given what you've written here you are being unrealistic in your expectations of both the school nurse's job and in one's capacity to control a low, especially lows in the 50s and under.

 

If you're having double and triple lows often have you looked at changing the way you treat lows. I know OJ is very slow for my son and apple juice is faster. Maybe pass it by your endo?

My son's school is also very difficult to deal with; so I feel your pain. I try to treat them as if they were just like me shortly after diagnosis. Worried, anxious and unsure and very scared to make a mistake especially regarding lows. I find it much easier now to deal with them because I look at them with a lot of compassion now.

 

At the second low, I usually put on a temp basal because something out of ordinary is going on. Would she do that for you?

 

Sarah,
I dont think you're being harsh at all I ask questions here to hear what others opinions are, and I dont get easily offended

Here's the thing: I do NOT trust her. This is the same nurse that, in the first 10 days of school, gave him the wrong dose of insulin 5 of those days and nothing was done about it. This is also the nurse that has told me on more than one occassion that she doesn't need my help, she's an RN and I'm not. So yes, the relationship she and I have is not a good one. We are moving at the end of this school year, and I've just been trying to get through these last 90 or so days of school, honestly. At his school, there is an aide specifically for the 4 Type 1 children in his school. We fought to have her and that is her only job. For some reason, when these lows were happening yesterday, she was not the one I spoke to. I heard her in the background each time, so I know she was there, but I feel I should just clarify that because I know there are 1000 kids in his school and he's not the only one at the nurse's office. He was, however, the only diabetic student in the clinic (per him), so that's why I get frustrated. This is also the same nurse who asked me to keep him out for another 4 days when we switched pumps (which I did not, but just to give you an idea of their level of wanting to deal with things).

Again, I'm not upset with anyone. I just wanted to know how others' nurses' would have handled the situation is all. Thank you for your honest feedback

 

DS knows how to do this, so he could. It's one of the things we taught him just last week because we had some extended lows after baseball practice one night. My understanding though is that isn't instant, right? Now I'm doubting myself, but I thought lowering his basal was not an instant fix. He did go low at 5pm yesterday (to 67), but we treated with 4 glucose tabs and he was back to 97 within 15 minutes and steadily went up from there last night until he settled around 125 nearly all night long.

 

The TBR is not an instant fix, but if you're regularly seeing lows that persist for more than an hour, it might be a good idea to turn down the basal by the time you see the 2d or 3d low. Last fall, we experienced a LOT of hard-to-treat lows, and the TBR was helpful in the painfully slow process of treating them. Our DD had different factors going on than your son (ours were less often driven by activity/exercise, more often by stomach issues), so the experience isn't completely analogous. I do think if you're seeing double and triple lows as frequently as you say, it's worth checking with the endo about how to manage them.

 

Thanks! His are directly related to level of exercise/activity and we've been in contact with our CDE. We also have our follow up appointment next Wednesday for his 30 day pump checkup, and I'm sure they'll make even more changes there. I think the hardest part is, we can have a day where he has PE/Lunch/Recess (where they play flag football every day!) and then 2 hours of baseball practice and he goes low and stays low for an extended period, and then we can do the same exact thing two days later, and he's high and stays high. And then we have a good amount of days where things are "normal" (if there is such a thing LOL).

 

Chris has a range where he is allowed to be active. Anything over 300 or under 90 and he has to reduce his activity level. He is highly sensitive to activity and he can either plunge or skyrocket depending on what his sugar is when he starts, which is why we have the range. Chris tests before PE and recess every day to see what he can do. Yes, it is unfair to an 8 year old boy, but he doesn't like how he feels when he runs low or when he runs high, so he's okay with the parameters.

 

Keep in mind that exercise lows can persist for hours after exercise - so even though you are treating the immediate low, you are almost fighting a losing battle because the exercise is gonna keep forcing it down for could be up to 2+ hours. On the days where he has PE / lunch / recess, can he set a temp basal about 1 hour before exercise starts - or underdose lunch to account for the exercise.

 

DO you know what the school policy is on back to back lows that do not rise after treatment?

In my district if after 2 treatments the BG does not come up to above 75 then I would be called. At that point while "you" are assuming that his BG just has not risen all the way yet they have to assume that it is possible that those carbs will not raise BG and that whatever caused the initial low may continue to lower BG instead.

A lot of this depends on what the district policy says which overrides what you would like to do.

 

maybe she was not aggravated by you per say but by the fact that her interventions were not working, after an hour and multiple interventions and only going up to an 87 after many carbs I would not be assuming that he was for sure his BG would be eventually go up.

I would assume that either there is something continuing to bring down BG or that he is not absorbing carbs normally, either one will play out differently.

Just yesterday my dd went low at 930 and only came up to 87 after a juice, the nurse could have sent her back to class but called me to talk about it. I told her to let her have her 1030 snack at 945 and to NOT give insulin and check at lunch. If her BG was high give a correction and cover lunch. Noon came around and she was a lovely 124. 38 uncovered carbs to raise BG to cover minimal IOB to target.

If the nurse had sent her back to class she most likely would have been low before lunch. I believe you nurse did a good job of handling he situation and most likely following her school policies which you will never be able to change. but need to understand what they are so that you can set correct boundaries and make sure your kid IS cared and accommodated for while at school.