The pump started screaming at 4:10 in the afternoon, and for the first few seconds Ruthie Dalby thought it was Teddy's ventilator, because in the apartment above the Suds 'n' Duds on Front Street every alarm sounded at first like Teddy's ventilator.
She was at the kitchen table with her fractions worksheet, and she was already halfway out of her chair, already looking toward the living room where her brother lay in his crib with the gray tubing curling out of the small white collar at his throat, when she understood that the sound was wrong. Teddy's alarm was a steady three-note chime, high-low-high, polite and relentless. This was a flat electronic bleat, and it was coming from her mother's hip.
Her mother was standing at the counter measuring formula into the feeding bag, and she did not stop measuring. She finished the scoop, leveled it with the back of a butter knife, tipped it in, and only then reached down and unclipped the insulin pump from the waistband of her jeans and looked at it. Ruthie watched her face. You could learn a lot from her mother's face if you knew where to look, and Ruthie had been studying it for ten years, which was her whole life, and with special attention for the last fourteen months, which was Teddy's whole life.
Her mother's mouth went flat at the corners.
"Okay," Lauren Dalby said, to the pump. "Okay. Don't do this to me today."
"What's it say?"
Her mother turned the little screen so Ruthie could see it. The pump was the size of a deck of cards, black, with a scuffed belt clip and a strip of purple washi tape on the back that Ruthie had put there in second grade so it would look less like a medical thing and more like something a person might choose. Across the screen in white letters it said MOTOR ERROR, and under that, INSULIN DELIVERY STOPPED, and under that, CALL CUSTOMER SUPPORT.
"Is it broken?"
"It's being dramatic." Her mother pressed a button, then another, then held one down until the screen went black and came back with the company logo. The logo dissolved. The alarm started again. "Okay," she said again, more quietly, and Ruthie knew from the second okay that it was broken.
Ruthie knew more about her mother's pancreas than most ten-year-olds knew about anything. She knew that it had quit when her mother was twelve, the summer of a stomach flu that never quite went away, and that her mother had been giving herself insulin ever since, first in shots and then through the pump, which pushed a tiny steady trickle of fast-acting insulin through a tube into a soft little cannula under the skin of her belly all day and all night. That trickle was called the basal. When her mother ate, she pressed buttons and the pump gave a bigger push, called a bolus, and when her mother's number got too high, she gave a correction. She knew that if her mother's number went too high for too long without insulin, something called ketones started to build up in her blood, and ketones were the dangerous part, because ketones could become DKA, and DKA was how her mother had ended up in the ICU at Akron Children's when she was twelve, before anyone knew.
She knew, too, that the trickle had no backup inside her mother's body. That was the thing people did not understand. A person with a working pancreas had insulin going all the time without thinking about it. Her mother had only what the pump gave her. When the pump stopped, everything stopped.