It Wasn’t The Insulin… Literally


I figured out what put me in the hospital.

I actually figured it out a few days ago, but I was so embarrassed that I didn’t want to talk about it. After a short talk with one of my board members yesterday, I’ve decided that to hold back would be bad.  I feel I have a responsibility to share what really happened.

I made a really stupid mistake, and it cost me a lot of pain and misery.  While it’s too early to tally up the financial figures (I haven’t received any of the hospital bills yet),  I’m sure it cost me a pretty penny as well.

The thing is, I feel that I was a victim of my own over-complication.  I feel that the whole experience was my fault.  There’s that guilt thing again.

I was just trying to make things work for me. In the end, it was a perfect storm of circumstances, bad timing, and good intentions.

I have been using Symlin off and on for about a year and a half now.  I think that it helps me, both in reducing the post-meal blood sugar spikes and in making me feel satisfied with less food.  But I struggle with having to take shots again.  I’ve been pumping my insulin for so long that I’ve gotten spoiled by the convenience and comfort of it.  I know – crazy for a person with diabetes to bitch and moan about shots.

I put our problem solving skills to use and figured out a way to take advantage of the benefits symlin was providing without having to take shots again.  I started pumping symlin in a second pump (an old, out of warranty pump).

Now, back to Wednesday night.  I was planning my twice-monthly overnight trip to Iowa for work, with a morning departure around 4:00 or 4:30 AM.  I had already worked a very long day and was really scrambling to get everything ready. I was also trying to get to bed early.  I was zipping all over the house trying to prepare, and I realized that I needed to change all of my pump stuff and put in a new Navigator sensor.

If you are a pumper, your care team should have taught you to never change your pump stuff out at night before bed.  My experience is a perfect example of why.  Until this happened to me I thought that I had good reasons to change my stuff out at night.  After this experience, I will do all I can to break that 12+ year habit.

To make a long story short(er), I loaded a cartridge of symlin into my insulin pump, and a cartridge of insulin into my symlin pump.  Don’t ask me how I did this, because I really couldn’t tell you.  My mind must have been thinking about a million things at once.  They don’t even look the same (I only fill my symlin cartridge about halfway, but I fill my insulin cartridge completely).

The symlin didn’t really hurt anything.  It just wasn’t insulin.  What about the other pump?  The one with insulin in it?  I don’t wear the second pump around the clock, like I do with the insulin pump, but even if I did, the basal rates are set so low that it wouldn’t have saved me.

If I had been awake I would have felt “funny” and would have started to investigate.  I would have had time to notice my blood sugars rising, and might have had a chance to fix things before they got to the point of no return.  But because I was asleep, I didn’t even know anything was wrong.  By the time I woke up it was already too late.

What about my Navigator CGM?  Shouldn’t that have alarmed me that my blood sugar was high?  I had put a new sensor in that night so it was still in the middle of its 10 hour calibration window (during which it does not give any readings or alarms).  Bad timing would be a bit of an understatement.

I’ve changed a bunch of stuff in my routine to try and avoid this mistake in the future.  I’m going to do all I can to not change my Navigator CGM sensor at the same time as my insulin infusion set.  I’m going to do all I can to not change both pump sets at the same time.  Finally, I’m not going to change my sets at night anymore if I can help it (even though I swear it takes the edges off the high blood sugar problems I have on a new site).  That is my plan.  DKA is no fun, and I’ll do whatever I can to avoid blood draws from my knuckles again.

It is still a great idea to check expiration dates on your insulin, but I don’t think there was anything wrong with the bottle I had.  The stuff I loaded into my pump?  It wasn’t the insulin.

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35 Comments on "It Wasn’t The Insulin… Literally"

2 years 9 months ago

I am a parent of a 10 year-old with T1D and over the past 4 years I have made a couple of these types of mistakes. I was more than embarrassed, I felt guilty, like I abused my child. I am so thankful for the G4 longevity and accuracy! I am definitely going to take your advice about not changing sensors and infusion sets at night before bed. Sometimes the sensor is whacky and takes a while to start giving results, that most of our G4s start working within 2 hours.


[…] one with insulin and his old one with Symlin. But then one day he got them mixed up. It ended badly, but thankfully, he’s still […]

6 years 21 days ago

I’m so glad you’re ok!( i’m just now catching up reading after a week with a cold) You know what?- we get into such a routine with things, that it’s easy to slip up. It’s like driving to work in the morning…sometimes we feel like we’re on autopilot.

6 years 22 days ago

Oh jeez, Scott. They say “no good deed ever goes unpunished”! I am so sorry for the discomfort & inconvenience. Who needed all that? Stupid, stupid diabetes!!

6 years 22 days ago

as others have said, we all make mistakes and this is totally understandable. i can understand feeling embarassed, i have felt that way, but seriously, i am not judging you for that and i bet noone else is either (and if they are they suck).
since switching back from the pump to shots, i thought i mixed up my lantus and humalog at night several times. and one time i thought i accidentaly took my morning lantus dose of 32 instead of my evening lantus dose of 5. i never actually did, but i stayed up all night twice to find out. and i definitely almost did many times.
i think they should make the bottles look more different. i don’t know what the symlin bottle looks like – but i think it should be so clear to even a tired hurried mind that it’s different! the lantus and apidra bottles look WAY too alike. when i was taking both i would scribble with a blue permanent marker ALL OVER the lantus to help remind me of the difference. maybe that would be another helpful safeguard for you if the bottles look at all similar?