Perspective/Type 1 Diabetes

Casey with his diabetic alert dog, Elvis.

On March 1 our 8-year-old son Casey celebrated three years of living life to the fullest with Type 1 diabetes (T1). But he had even more to celebrate on this diaversary (day of diagnosis) thanks to the generosity of the many people who helped to gift him something extraordinary—a diabetic alert dog.

Just days before, Casey had been standing in our driveway excitedly counting the minutes until Elvis’s arrival. As the car pulled up, Casey and his siblings peered into the open window to see his long-awaited companion. As Elvis hopped out of the car, we greeted him with irrepressible excitement.

Casey took Elvis onto the grass, kneeling to connect more intimately with him. We watched as he gently patted Elvis’s head, and they silently gazed at each other. Casey couldn’t stop beaming. They walked, then ran, around the playing field, just the two of them. A bond was forming before our eyes.

Elvis had received nearly two years of training in all skills required of service dogs working in public places and performing tasks specific to Casey’s diabetes. But training is not a once-and-done affair. His trainer had us learn and practice basic everyday commands, such as sit, down, stay and come, as well as reinforce correct responses by immediately rewarding Elvis with a treat and a “Good boy!” We all went to a store and restaurant for Casey to practice his handler skills in public spaces.

Elvis’s primary duty is to alert Casey or his parents whenever his blood glucose (BG) is below 80 or above 150. He alerts, often persistently, by putting a paw on your leg, usually with an expectant look. We were amazed when Elvis alerted Casey soon after meeting him (BG 189). It seemed miraculous. It was beyond exciting when Elvis alerted my husband Sam and me for the first time. Best of all was noticing Elvis alert Casey more often than us. He was learning that Casey is his handler. Their bond is strengthened by Casey taking Elvis with him everywhere, even inside the house and to school next fall, and by Elvis always wearing a leash, which generally only Casey holds. Apparently adapting quickly to our active and boisterous children, Elvis didn’t hesitate to alert Casey while he was wrestling with his younger brother.

We also practiced the more complex process of responding to Elvis’s alerts, which requires issuing a series of commands. One evening Elvis alerted me when I discovered Casey had fallen asleep early, so I did a full night alert drill with him. I said, “Let’s check” and did a finger stick. Casey’s BG was out of range (160), so I said, “Let’s go tell dad.” Sam and I were thrilled when he alerted Sam too. By asking “What is it?” Sam signaled Elvis to alert again, which he did, and for which Sam rewarded him with a treat and “Good alert!” Not long after taking Elvis back to Casey’s bedroom, he came into the living room and persistently alerted me again. This was the first time he had come into another room to alert us. Had the fingerstick indicated normal BG, I’d have said “We will watch it” because Elvis might have been catching a rise or fall in BG.

Casey loves to snuggle with Elvis on Elvis’s couch bed in the living room, practice obedience training, and take him outside to play. Playtime allows all family members to bond with him. Elvis loves fetching and returning balls, which we hope to generalize into retrieving diabetes supplies. For playtime indoors and to exercise his brain, we play hide-and-seek where Elvis comes to find us. We also have puzzles requiring him to figure out where treats are hidden and how to retrieve them. We love seeing more of his personality as he settles into our family.

Several days after Elvis arrived, we took him on a two-day trip to a busy mall with many children’s activities. It went well because Elvis was learning to trust us, and Casey was already confident as his handler in busy settings. We give Elvis lots of reassurance in new settings. While he’s sometimes nervous, it reassures us to see how well he handles sudden noises, other dogs, and the commotion of large groups. We give him breaks during times of prolonged stimulation. At restaurants, Elvis makes himself comfortable under the table, and most patrons never realize he’s there.

Elvis already alerts well during the day, but only we can provide the extra nighttime training he needs to consistently alert when everyone (including Elvis) is asleep. For that, we must train Elvis every evening for at least six months. All T1 parents fear finding their child “dead in bed” from severe hypoglycemia. Apps that warn parents of plunging nocturnal BG sometimes fail, as ours did one night. Elvis will be our failsafe—if we train him well.

We train for nocturnal alerts using frozen cotton balls soaked with Casey’s saliva from prior episodes of high or low BG. From his bed, Casey discreetly blows on several toward Elvis where he sleeps beside Casey’s bed. The goal is to get Elvis to alert. When he does, Casey says “Let’s go tell Mom and Dad” and, with a “Come” command, brings him to our bedroom to alert us too by placing both paws high on the bed or jumping up. Bringing Elvis to our bedroom trains him to come to us when Casey isn’t responsive.

As we’ve seen more alerts, we’ve discovered some puzzling discrepancies between Elvis’s alerts and readings from Casey’s continuous glucose monitor (CGM). Elvis has sometimes alerted us to out-of-range BG when the CGM says it’s normal, and vice versa. It’s crucial that Elvis be alerting correctly and that we reward him for all (and only) true lows and highs. That’s why we immediately check the validity of all alerts by inserting a sample of Casey’s fingerstick blood into a handheld glucometer. It measures BG in the current moment, whereas sensor glucose (CGM) readings capture BG levels about 20 minutes in the past. When Elvis failed to alert Casey but the CGM said he was low (70), finger sticks revealed that his BG was perfectly fine (115). Before Elvis, we would have given Casey glucose tablets for the low CGM reading, inadvertently sending his BG high.

Now we remind ourselves not only that CGMs commonly give faulty readings near their 10-day expiration, but also that non-faulty CGM sensor readings are a lagging indicator of BG, meaning they’re more off the mark when BG is changing quickly. The limitations of CGM readings may help explain another perplexing discrepancy. One day both Elvis and the CGM alerted us, but a finger stick revealed that Elvis was alerting us to rising BG (141) approaching his 150 threshold, whereas the CGM indicated glucose was very low (61). We are learning to keep the limitations of all our BG indicators in mind while exploiting their unique advantages for keeping Casey safe and healthy.

While Elvis is our failsafe for Casey, he’s also a loving addition to our family. Thank you to everyone who so generously helped Casey get his dear new companion.

Lisa Seitles

Hammonton

Lisa Seitles and her husband Sam are the owners of READ Preschool and Camp Tuscaloosa. They have four children and are active members of the community.