Need help navigating life with diabetes? You can always Ask D’Mine!

Welcome again to  our weekly Q&A column, hosted by veteran type 1 and diabetes author Wil Dubois. This week, Wil’s addressing what to do if your hands don’t cooperate for blood glucose testing. 

{Got your own questions? Email us at AskDMine@diabetesmine.com}

 

Nancy, type 3 from Nevada, writes: My friend has tremors of her hands that makes glucose testing essentially impossible. At each attempt to fingerstick, she usually sticks her finger 10 times, takes a long time to hold blood to the test strip, and gets blood everywhere if she can even get the two together. Suggestions?

Wil@Ask D’Mine answers: You bet, I’ve got a fist full of suggestions! To paraphrase a seven-year-old boy: “Look Ma, no fingers!”

But seriously, this is a real problem, and my heart goes out to her. Hand tremors turn daily tasks into massive challenges, and make any task requiring two hands—like fingerstick testing, as you point out—nearly impossible. To help solve her problem may I suggest cutting off one hand? Out. Not off. I meant to say cutting out one hand.

Sorry about that. Let me get some more coffee.

OK. I’m back, and I’m on my game now. Part of the problem she’s having here is that she’s trying to connect two moving targets. Another part of the problem is that the targets are small. But by switching to what are called alternative sites, testing somewhere else other than her fingertips, she can remove half of the problem. What are alternate sites? Developed for pansies with delicate fingies who were pain adverse, alternate sites are simply other locations on the body, with fewer nerve endings, where a blood drop can be more or less easily attained. The most common alternate site is the forearm, but I don’t recommend it for your friend.

Why am I so quick to diss the forearm? Because it actually takes some work to get a good blood drop out of the forearm. The blood-rich capillaries are deeper in the tissue there than they are at the fingertips. The normal procedure is to use the clear cap on the lancing device, which allows the lancing needle to strike deeper—but that alone is not enough. You also need to pump the lancing device up and down to draw some blood up to the surface. That’s why it’s clear plastic, so that you can see when you have enough blood. Given her tremors, I don’t think that would work. Nor will another common alternative site, the calf, for the same reason. A third site, the palm—with its rich bed of capillaries near the surface—doesn’t meet our goal of cutting out one hand. 

But not to worry, there are other possibilities.

Back when I was working the front lines of the diabetes epidemic in the healthcare trenches, our clinic had one patient whose neuropathy made Dante’s Inferno look like a Sunday picnic. Hell… I mean, Hades, I bet brushing his fingertips with a feather would have given him cascading paroxysms of agony.

So what to do about testing his blood sugar?

We found that while his neuropathy affected nearly every inch on his epidermis, his earlobes were unaffected, so instead of fingersticks, we did ear sticks. Not that I’m recommending that for your friend, it would be no easier for her than a fingertip, but the point is that anywhere you can get blood, you can test it.

In hospitals, if nurses need a blood drop from a baby (whose fingers are too tiny for stabbing) they go for the very bottom of the bundle: The heel. I suggest your friend should baby herself.

Yep, assuming your friend is limber enough, I think testing on the side of her heel is going to be the best bet. The target is waaaaay larger than a fingertip, and it doesn’t have a tremor. With one shaky hand, I’ll bet she can successfully lance a non-moving target the size of her heel. Granted, maneuvering the meter and strip to the blood drip will still be an exercise in frustration, but at least only half the target is in motion, and it’s easier for one shaking hand to mop up a blood smear on a stationary target than for two shaking hands to try to clean up each other.

Now, the downside of most alternate sites is that the readings tend to lag farther behind than fingertip readings, making them inappropriate for checking fast-moving sugar changes, such as confirming suspected hypoglycemia

Why is that?

It has to do with the architecture of your body’s plumbing system. Blood circulates through a mind-boggling 60,000 miles of arteries, veins, and capillaries. Obviously, if there’s a sugar shortage—a hypo—it’s not going to affect the entire 60,000-mile system at once, as blood only moves though the body at about four miles per hour. Bottom line: Any changes that take place in the blood take a while to migrate system-wide.

Of course, the circulatory system isn’t one long tube. Lucky thing. If it were, it would take nearly two years for a blood cell to travel from one end to the other. Instead, the system is more like a river system in reverse, with large branches breaking down into continually smaller tributaries, so any change in the blood takes around 30 minutes, instead of years, to travel throughout the system.

Speaking of mind-boggling, our brains, in order to function properly, are huge sugar hogs, gobbling up a full 20% of the body’s glucose. As such, the brain is pretty high up in the delivery system. Not true of the forearm. Thus, when sugar drops, it will hit the brain first, the forearm last. If you’re testing only on your forearm, you can give yourself a false sense of security about the status of the blood sugar feeding your brain.

On the bright side, the heel—like the palm (and the earlobe)—is much closer to the accuracy of a fingerstick than the majority of the alternative sites. Yep, even though the brain and the foot are at far ends of the body from each other, they aren’t on the far ends of the circulatory system.

I think that a heel stick is the best solution for your friend using traditional materials, but, of course, I’d be remiss in not suggesting a technological alternative to test strips, such as the FreeStyle Libre, a “flash” continuous glucose monitoring system (CGM). This tech marvel consists of a sensor that’s worn on the upper arm for two weeks, which keeps tabs on your blood sugar, and a hand-held wireless “reader.” Passing the reader over the sensor—like a magic wand—reveals the blood sugar lurking in the tissue beneath. How frickin’ cool is that? 

Insurance coverage for these systems is good and getting better, and given her tremors, her doc should be able to get it covered.

Now, all CGM sensors read the sugar found in something called interstitial fluid, the water between cells. This fluid is at the very bottom of the flow of sugar throughout the circulatory system, so it’s “old news.” Even worse than the laggiest of the alternative sites.

But still, CGM is a heck of a good way to track blood sugar, and while sometimes lacking in up-to-the-minute accuracy, it benefits from providing trend information. The Libre takes a blood sugar reading every minute, regardless of whether or not it is “read.” So if you were to scan the sensor just once every hour, it would still provide information on the last 59 readings, and display them on a graph on the reader. If your blood sugar is dropping, even if the exact number in the moment isn’t correct, the trend is clearly apparent.

So either back-to-baby basics of a heel stick, or with the latest and greatest D-tech, there’s always a way to check blood sugar. Even with tremendous tremors.

 

This is not a medical advice column. We are PWDs freely and openly sharing the wisdom of our collected experiences — our been-there-done-that knowledge from the trenches. Bottom Line: You still need the guidance and care of a licensed medical professional.