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A simple pump mistake - a rush to A&E

Discussion in 'Insulin Pump Forum' started by Doug88, Sep 28, 2021.

  1. Doug88

    Doug88 · Member

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    Hi all,

    I thought I'd share a story here of a mistake I made yesterday just as a wee warning for others. The mistake was simple, it only took 1 second of not thinking, but it ended with my wife having to rush me to A&E.

    Backstory
    So for the last week my basal insulin requirement has been around 30% higher than usual and I've been trying to work out what might be behind it - is it a honeymoon period ending? (maybe) is it a dodgy infusion site (nope - changed it several times) is it a change of activity level (nope - I'm a creature of habit).

    Then I got the idea that maybe the insulin in the vial was bad - I had started a new vial just at the start of the week - so I decided to change the insulin by putting a new resevoir in my pump. As I had just changed by infusion site, I thought I would save some time by only changing the resevoir and connecting it through the same infusion site.

    The Mistake
    So I took out the old resevoir, attached a new one and clicked it back into the pump.

    What Went Wrong
    Thats when I felt insulin getting pushed into my stomach, and it felt like a lot. I quickly pulled out the resevoir and instantly realised my mistake, I hadn't rewound and reset the pin that pushes the base of the resevoir to push insulin up through the infusion set - its a medtonic 670g (the mechanism is a bit like a colgate toothpaste thingy). I looked at my old vial it and tried to compare it against how much I thought I'd filled up the new one, that difference was how much insulin I might have just pushed up into me. A quick bit of maths told me that it was waaaaay too much. (Rather than say numbers here, I'll just say that it looked about 20x - 30x a normal dinner time bolus).

    What Went Right
    Well I quickly realised how much trouble I might be in, I grabbed some carbs, ran and got my wife, grabbed some more carbs, started explaining what had happened and we decided to rush to hospital and managed to get through the 5 hours of insulin activity time before I was kinda in the clear again. It was weird that later that same day, the crises was basically over.

    So yeah, I dunno what the moral of this story is - be careful I guess. To be honest it was such as simple mistake that I'm not sure I would judge anybody else for making it. I'd never heard of somebody doing it before so hopefully just hearing this will stop somebody else making the same mistake.


    Doug
     
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  2. NicoleC1971

    NicoleC1971 Type 1 · Well-Known Member

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    That is a classic! Tubing error. Have done the reverse in which I couldn't be bothered to fill the tubing bit (12 units worth of tube) so there was air going in but no insulin.
    Other classic error pre pump was dosing bolus at the basal rate whilst drunk . I haven't enjoyed ferrero rocher chocolates since having to eat them all night after that one.
    Also reminds me why overdoese by insulin makes a great murder plot line in real life and in crime dramas! Just waiting for the insulin pump plot twist where someone blue toothes in the fatal dose...
     
  3. In Response

    In Response Type 1 · Well-Known Member

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    Well done on being quick to realise @Doug88.
    I now have a patch pump so this is unlikely to happen but I used to have a tubey pump and I am sure it always primed when I closed the cartridge cap. I used to find this a faff because it wasn't easy to see how much insulin was left without doing so (or maybe I failed to see it on the screen) so I didn't always want to wait for the priming. It seems like an easy safety mechanism.
    When I design and insulin pump ... :)
     
  4. Doug88

    Doug88 · Member

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    hahaha, I would so watch that movie. Yeah, I wish I'd had better food at hand yesterday, a nice big risotto or dominos pizza would have been so much better than running gels (pretty much only grabbed running gels). urgh!
     
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  5. Doug88

    Doug88 · Member

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    Yeah, the noticing it quick part of this story kept it from being a really rubbish day. We live pretty close to hospital too, so we were there just as the bloods started crashing.
     
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  6. Antje77

    Antje77 LADA · Moderator
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    Looks like you've perfectly handled it! :)
    I'm on pens, so I did the basal/bolus switch a while back. I live alone, so I went over to my neighbour, woke him up and informed him he was going to spend his night playing board games with me while I stuffed my face. :hilarious:

    Love your profile pic by the way. Nothing better than driving with a white pet in your neck! :D
     
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  7. Doug88

    Doug88 · Member

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    hahaha just saw your profile pic. it's a classic style.
     
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  8. sleepster

    sleepster Type 1 · Well-Known Member

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  9. Doug88

    Doug88 · Member

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  10. NicoleC1971

    NicoleC1971 Type 1 · Well-Known Member

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  11. Dustydog

    Dustydog Type 1 · Member

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    Probably not the same but just for information. I currently use the Roche Insight pump and a few weeks ago went to change the insulin cartridge and wondered why it was taking so long only to find that the cartridge was actually empty. No its not a senior moment as I had both the old and new cartridge to hand.. Wondering if anyone else has had anything like that happening?
     
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