LifeAfterDx--Diabetes Uncensored

A internet journal from one of the first T1 Diabetics to use continuous glucose monitoring. Copyright 2005, 2006, 2007, 2008, 2009, 2010, 2011, 2012, 2013, 2014, 2015, 2016

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Location: New Mexico, United States

Hi! I’m William “Lee” Dubois (called either Wil or Lee, depending what part of the internet you’re on). I’m a diabetes columnist and the author of four books about diabetes that have collectively won 16 national and international book awards. (Hey, if you can’t brag about yourself on your own blog, where can you??) I have the great good fortune to pen the edgy Dear Abby-style advice column every Saturday at Diabetes Mine; write the Diabetes Simplified column for dLife; and am one of the ShareCare diabetes experts. My work also appears in Diabetic Living and Diabetes Self-Management magazines. In addition to writing, I’ve spent the last half-dozen years running the diabetes education program for a rural non-profit clinic in the mountains of New Mexico. Don’t worry, I’ll get some rest after the cure. LifeAfterDx is my personal home base, where I get to say what and how I feel about diabetes and… you know… life, free from the red pens of editors (all of whom I adore, of course!).

Wednesday, November 30, 2005

Happy anniversary, baby.

Yesterday was my one week anniversary on the Guardian. It seems like a good time for a review. So do I like it? Absolutely. Is it worth what it has cost me? Double absolutely. Would I do it again? Triple absolutely.

If someone put a gun to my head and made me choose between the Guardian and my pump, which would I choose? Hmmmm.....that’s a tough call, but I think the new girl would win. You can have very good control with shots, although I found it hard to do. In theory you have better control on the pump, but I’ve found that’s not always the case either. I think if you had to choose, the real value is in knowing your sugar and reacting as needed...the method of control is less important than the control itself. Guardian gives you the real time, all-the-time info you need to keep in control. (That having been said I’m in nooooo hurry to be rid of my pump!)

We’ve had a few hiccups this week, but for the most part everything has gone very, very smoothly. I did have some trouble with the second sensor, especially on one particular day, but the rest of the time the numbers have been dead on with my BG meter. I did lose telemetry, which scared/depressed me at the time, but now I know what to do if it happens again and I will recognize it as a minor inconvenience, not a travesty.

The security of having an early warning system has been great. The convince of performing post-meal BG checks with a glance and a click has been wonderful.

....and, this is big folks; I haven’t even scratched the surface of the other 50% of the reason for having a Guardian: analyzing the BG data and making therapy adjustments. Why haven’t I done that? Well, it has been Thanksgiving week. Nuff’ said.

Are there some things I don’t like about it? Well, I do have a few gripes. In no particular order they are:

The battery indicator (or lack there of). She'll let me know 8 hours out that the battery needs to be replaced. But that is all the warning I get. I just know it will always be at 2 in the morning when that alarm goes off. My Cozmo, my PDA, my lap-top, my cell phone, and my digital cameras all have little indicators that tell you about how much juice is left. You can glace at any of them before going to bed and say, “well that'll be OK until morning,” or you can do something about it if it looks really low.

A BG trend indicator would be really nice. I can look at my current reading, I can scroll backwards and see what it was 5, 10 ,15 minutes ago. But an arrow showing an up trend or a down trend would be nice.

There is a nice, bright back light for the screen when you use it at night, however, it does not light up the keys. The keys are “raised” so in theory you can feel them, but in reality, when she’s in her case you can’t feel them through the clear vinyl.

I have a few quibbles about the software, but I’ll get into that when I post about the software in detail in a few days. So: full report to follow, and mostly thumbs up!

I had expected to have a love/hate relationship with the transmitter due to its size and weight. But in reality this has turned into a non-issue and I never even think about it. I’m on my third set, and each time the transmitter has been on a different location on my stomach. In all three places it is NOT at bother what-so-ever.

I also got over my attack of chicken-shitness and used the inserter on Monday when I put in my third sensor. It worked great, was much faster, and drew no blood. I’m going to use the inserter from now on.

These are all minor bitches, things you might hope to see changed in the next generation Guardian, but none of them are deal killers, because, what is my blood sugar, you ask? Well, I don’t know, let me check. Click. 131. Thank you for asking. Hee hee hee. I never get sick of doing that!

Monday, November 28, 2005

Failure and rescue

I've known for a long time that God has an ironic sense of humor. I was reminded of that on Sunday at the Denver Museum of Nature and Science. I'm in the Hall of Life on the second floor looking at Health Exhibits with my three-year-old, Rio. No kidding, while I'm reading a display on Diabetes my Guardian alarms to tell me she's not working. Oh shit.

There is no telemetry and for the last 10 or fifteen minutes I have no data. Oh shit. We’re doing a lot of walking. I tend to get hypo when I exercise.

So three-year-old in tow, with a stroller, my emergency bag, his supply bag, and our coats I’m off to find the nearest bathroom to check the sensor set and try to figure out what’s going on. “Daddy, I’m not ready to gooooo!” We gotta go, NOW.

In the bathroom, after getting myself and the stroller caught in malfunctioning automatic door for wheel chairs, I find nothing seems to be wrong with the set. Of course, what is there to see? The transmitter is still plugged in to the sensor, and senor is still plugged in to me. Well, shit.

“Daddy, I’m hungry. Hungry. Hungry. Hungry.” OK, well I can’t think what to do, my mind is numb. Better feed the little one. Down we go to the T-Rex Cafe. Juggling stroller, bags, jackets, three-year-old; and now a tray with a salad for me and salad and fruit for the little one. Did I mention that my wife and my mother are off on a separate adventure, leaving us “men” to fend for ourselves at the museum? I have a new appreciation for the difficulties faced by single parents....

Finally after getting us through the line (twenty bucks for a couple of salads???), and out to the tables, and then back to the cash register for the plastic “silverware” and paper napkins I’d forgotten, and then back to the tables; my mind quickly goes through anger, confusion, despair.

Anger: this damn thing is brand-new and already it broke!
Confusion: what the hell am I going to do now?
Despair: can’t cry in front of the boy! ;-)

I’ve left the manual at home. I’ve left the test plug at home (the test plug is a device tech support can use to check the systems). I’m not carrying my spare sensor with me, it’s back at the room in the fridge. I try to work out what to do next with my limited knowledge of the system.

Monitor read outs are functioning. The back light is bright. So it is not likely to be the batteries. I’m not getting a telemetry icon. So it would seem that the transmitter is not sending out a signal. The transmitter is supposed to last a year. I’ll be pretty irked if it lasts less than a week. I’ve had some weird readings on this sensor. Could it be a bad sensor? If a sensor starts to get used up I’m supposed to get an alarm to warn me it needs to be replaced. I haven’t had that alarm. If a sensor did fail, would that cause the telemetry to fail too?

I’m thinking to myself that I’ll trying changing the sensor when I get back to my room and see what happens. If that fails I’ll have to wait until I get back to New Mexico. Then it occurs to me: maybe it is something simple. Maybe it is something that Medtronic can help me with. They have a 24-7 tech support line. Do I have the number? I take the monitor off my belt and slip it out of the case. I remove the belt clip, and thank goodness the 800 number is printed on the back of the monitor.

I’ve finished my salad, Rio is still working his way through a mountain of fresh fruit--dipping watermelon chunks and strawberries into ranch dressing. I get out my cell phone and call. I’m very quickly talking a real person. I explain the problem. The young lady at tech support starts taking me though a series of checks to narrow down what the problem could be. We confirm that the monitor knows the transmitter’s number. We check a couple of other settings. I’m starting to get depressed. My contact tells me to try initiating a search. This is the same procedure you use when you’ve put a new senor in. The monitor starts an 8 minute count down during which there is an electronic mating dance between the sensor and the monitor. Of course with a new set, you start the count down, plug in and in an instant they are linked up. I start the count down and then my Rio says:

“Daddy, I have to go to the bathroom.” You gotta be kidding.

Now I don’t know how many of you either have, or have had, three-year-olds. But when they tell you they need to go, the clock is ticking and you haven’t got much time. So off we go, three-year-old Rio, stroller, bags, coats, cell phone on shoulder, monitor out of case, belt clip off; now with a bottle of water and a bottle of strawberry milk to add to the load.

Is it possible to call you back? I’m figuring in the middle of this I’m gonna end up dropping either the cell phone or the Guardian in the toilet. She gives me her name, wishes me luck and tells me to call her back as soon as I’ve got the situation under control.

About ten minutes later, I situate us and our gear in a more quiet corner. I pull the Guardian out of my pocket. She’s working again. I call my contact back for a post mortem.

Her best guess: some sort of radio interference (maybe from the electronics in the museum exhibits?) interrupted the telemetry link. I’m told that cell phones sometimes do this, as do some types of computer equipment. Usually if there is a break, the two will link up again. If the interference goes on too long a manual search needs to be done. She’s not sure the length of time.

That’s OK. She’s got me up and running again; and I know what to do if it happens again. And Rio and I are off to see the Egyptian mummies...

Saturday, November 26, 2005

Travel update

Well the car is half loaded, the weather is wonderful, and it is time for a road trip! I mention this, because last night I was having some equipment trouble and I figured if I didn't post for a few days you would all assume that my Guardian had failed me and I was in a diabetic coma.

Well, in fact, the children are playing well together this morning. Both the Guardian and the Cozmo BG meter were seeing eye to eye at wake up and two hour post breakfast. Who knows what caused the trouble last night. It did bum me out though, big time. Up to that point things were almost too perfect. Looks like we're back on track now, only time will tell how often this kind of thing happens!

In twenty five years I’m willing to bet that continuous monitoring will be the standard and our little BG meters will be as obsolete as urine test strips are now. But this is now, not the future, and we are on the cutting edge. Is this technology really ready? That is what this blog is all about.

At the risk of suffering withdrawal, I'm leaving my lap-top behind this trip. I maybe able to post via my Mom's computer if I have a chance, but don't panic if I don't post until Monday night or Tuesday. Talk to you soon!

Friday, November 25, 2005

When the children don't get along...

I’m minding my own business, listing things on E-bay when the Martians land again. Hypo alert! Wow...didn’t expect that. But that’s why I have a Guardian. I’m expecting it to be at 80, which is where I’ve set my low threshold.

Threshold’s are the BG point at which you set your Guardian to alarm. On the low side you can choose any number between 40 (yeah, like I’m that brave) and 100 mg/dl. On the high side you can choose any number between 105 and 400 mg/dl. Well one size doesn’t fit all, after all. But nothing is that simple.

The Guardian samples every five minutes. That means if you are dropping fast here is what could happen: 15 seconds after a sample your sugar passes through your low threshold. OK, now you’ve got four minutes and 45 seconds before the next sample “catches” the low. How low will you drop in that time?

Well, my example is extreme, but you understand the principal. Medtronic suggests you set your low threshold higher than you’d think to offset this phenomena. My rep/trainer asked me at point I usually treat hypo. My personal comfort zone: if it is below 70 I’m eating some sugar. She recommended I set the low threshold at 80. Makes sense. I think I might get some alarms that don’t really need to be treated, but I’m covered better if a fast-moving low hits me. Besides, I’ve got no business being much below 80 anyway.

Obviously, if you’ve been hanging out around 90 most of the day and you haven’t taken any insulin for four hours you wouldn’t take much sugar on board for a low alarm. Conversely, if you had just indulged in three bagels and a banana split and had a boat load of insulin on board....
Any way, back to the story...I look down, expecting 80. Instead I have 76. Yikes! That’s a surprise and indicates to me that I’m dropping a bit quickly. So I skip the finger stick and take on a small bit of sugar. According to the pump I’ve got zero IOB.

I go about my business. Now, if you have you Guardian set to simple “on,” then five minutes later, if you are still low (and you will be) you’ll alarm again. I’ve got both my alarms set to “Repeat” mode. This lets me customize the length of time between alarms. Kinda of like a built in snooze alarm you can program to be the same each time. I’ve got my low alarm set for 20 minutes. This is what we all do now. You are low? You eat sugar. Wait 15-20 minutes to see where you are at and go from there. If I’m still below 80 in 20 minutes after the first alarm the Guardian will alarm again.

But for some reason, I look at the screen in about 10 minutes. Yikes! I’m down to 60! What the @#$%#?? I just took on sugar, I should be going up. So I eat another half-piece of my emergency candy. Then it occurs to me to do a finger stick. Cozmonitor has me at 126.

So what to do when the children disagree? They’ve always been neck-in-neck. I know that the Guardian is supposed to be more accurate on the low end, and that it detects impending lows more quickly than a finger stick would. Still 60 vs. 126 seems like a bit of a wide spread.

I can’t trust my feelings, because I don’t have any. Impaired hypoglycemia awareness, remember? As a general rule, I say it is better to error on the side that keeps you alive. Better to correct for a low that isn’t there than to not correct for a low that is there.

From my past experience I know that a full piece of my stash candy will always pull me out of mild hypo with low or no insulin on board, as I’ve had two one-half hits I decide to ride it out a bit and see what happens. Guardian bottoms out at 53 while Cozmonitor continues to climb. At one point they have a 100 point spread between them. Damn.

Oddly, however, one hour after all this started they are with in a few points of each other again.
Not sure how to explain this....One possible theory: the Guardian was more on the ball in detecting the hypo when it started--just like it is supposed to do. But once the recovery began the finger sticks were more accurate. Perhaps the traditional blood readings responded more quickly to rising sugars while the I.F. readings responded more quickly to dropping? I do know that the Guardian system lags at very high BG.

Hmmmm.... the traditional glucose monitor folks say not to use forearm testing for fast changing BG. With rapidly shifting sands everyone agrees that finger tips are the way to go. Is I.F. like the forearm? In other words, good most of the time, but behind the 8-ball when the fur is flying? I’ll need to get due more research and get back to you folks on this. (By the way, all of my traditional checks are finger tip.)

Well, crap. While I was finishing off this post the Guardian set off a high limit alarm. She’s showing 200 while Cozmo shows mid 150’s. I give up. Some days nothing works right. I’m going to bed.

Site change--a photo essay by Debbie

So let's have a big round of applause for my wife, who got up earlier than usual to document the first site change for the Guardian. (By the way, this is the same woman who is behind the famous 20 carb Hot Fudge Sundae at DiabetesTalkFest.)

OK, this first image has nothing at all to do with the Guardian. I’m loading my Cosmo cartridge with insulin, but I just loved the image so much I had to post it. One of the issues facing diabetics who use both pumps and Guardians is whether or not to change sites for both machines on the same day. On one hand, it makes sense to do them on separate days. The reason for this is that there is a two hour window after insertion while the sensor is initializing where it does not work. If something also went wrong with your pump you might like to have the Guardian on the job. On the other hand, how many days per week do you want to get up and stick stuff into your body?

I suspect many users will do what I did. The Guardian happened to arrive on a site change day, so I opted for all-at-once. I’ve had very few pump set problems, and the very few took more like six hours to become a mess anyway. I think I’d rather do it all every three days than have to spend the majority of my mornings messing around with this stuff.

I’ve taken the sensor out of it’s little sack, letting it get up to room temperature first. Here I’m removing the needle guard. You can see it is a big honking needle. I’ve also prepped the skin with an alcohol pad. No IV prep, apparently that will mess up the readings.

Next you peel back the paper that covers the front half of the sensor’s adhesive pad.

Insertion. Sorry that I couldn’t find someone with a sexier stomach than I’ve got. All the people I know with sexy stomachs declined to have a fat needle stuck into them. Go figure.

Once the needle is fully in and the front tape against the skin, you pull the tab that pulls the backing paper off of the back half of the adhesive. I really like this feature. Quick and easy.

Once the adhesive pad is smoothed against your skin, pull out the guide needle. The sensor stays under the skin and the set is secure on your tummy.

The transmitter pad has double-sided tape. Side one goes against the back of the transmitter...

I set the pad down to center it, and firmly press the transmitter onto the adhesive.

Once affixed, then you peal off the back of the pad and....

Press it firmly onto your skin. Not shown here, but before I peeled off the backing tape I slid the transmitter around a bit to pick a spot, making sure the wire reached comfortably.

IMPORTANT: Before you hook up the transmitter to the sensor, you need to get the Guardian ready. You put the Monitor in search mode. It is now looking for a signal.

Plug the transmitter into the sensor. Very quickly the monitor will display “Success.” You have telemetry and the monitor is receiving the signal from the sensor. The monitor now starts initializing the sensor, a process that will take about two hours. During that time you will not be getting glucose data. At the end of the two hour period the Guardian will squawk at you, asking for a finger stick to calibrate itself. You need to feed it two finger sticks per day, 12 hours apart to keep in in calibration. More on that in a later post.

Transmitter and sensor ready for action!

You need to cover the seam between the sensor and transmitter with an IV 3000 dressing. The dressing is about the thickness of a piece of skin, and sticky on one side. Kinda tricky to work with if you aren’t used to them. This provides water proofing.

You remove the backing covering the sticky side and smooth the dressing down as best you can, then...

You peal off the top cover of the dressing, just leaving the “skin”

That’s it! You’re good to go for another three days. The monitor is showing a countdown at 2 hours, 19 minutes here. Once you plug in it starts a count down of two hours 20 minutes for the initialization. Based on the two times I’ve done it, it finishes up early. In the upper left is the current time. The funky little symbol below that shows a strong telemetry signal.

Thursday, November 24, 2005

Nuts and bolts

OK, time to dig into the nitty-gritty of the system. Warning! This is a long post, even by my standards. You might as well brew a cup off coffee, put a DVD on for the Kids, send your mate out on a shopping spree, and find a comfy spot to sit and read!

There are three components to the system and a couple of accessories. From the body out-wards the components are: the Glucose Sensor, the Transmitter, and the Monitor. Oddly, while we have a transmitter, we have no receiver--the monitor does the receiving. Hey don't blame me, I'm just the fan club. No one at Medtronic consulted me when naming the parts!

Accessories include the computer dock called the Com-station and software named Guardian Solutions, the Sen-serter for quick insertion of the sensors, a Test Plug for diagnostics, a leather belt case for the Monitor, and even a screw driver for the monitor's battery door.

Everything arrives at your door satisfying packaged in black-foam filled boxes with custom cut outs for every piece of the system. Appealing to the photographer in me, it reminded me of a well organized camera bag. Which is moot of course, because it all goes “to work” at once and will never be put back in the box again! I'm sure the real purpose is to protect the gear in shipping anyway.

We've talked quite a bit about the sensors, but I'll review. You'll spend nearly five thousand dollars on sensors over the course of the year. (But if you add up how much you spend on test strips now, you’ll probably have a heart attack.) The sensor is inserted under your skin much like an infusion set and reads glucose from your interstitial fluid. I.F. is the liquid between your cells. Biology 101: your body runs on glucose. It is the energizer battery that fuels your brain, lungs, heart, and all of your muscles. It is sometimes hard to grasp, as we diabetics often view sugar as poison; but all of our cells “eat” sugar. Everything you put into your mouth, from T-bone steaks to Twinkies turns into sugar. Some foods just do it faster than others. The cells get their meals from the sugar in the interstitial fluid. Bottom line, there is a direct correlation between your blood sugar and you I.F. sugar. I don’t honestly know if the numbers are really the same but the Guardian gives us BG readings based on the readings it takes from the I.F. I can personally attest to the fact that the readings are very accurate. Over my first two days I’ve been taking quite a few finger sticks to compare the Guardian readings to the readings of my traditional meter. I’ve been astounded by how close the two are. I already have great confidence in the readings from my Guardian.

What else can I tell you about the sensors? They are pink. Well, maybe pale purple. Although....Now that I look at the one on my bod again it looks clear now. they change color as they get used up? Interesting. Well time will tell, I’m still on my first set, you know. The sticky pads are really well designed. You pull the front part off before inserting, once it is on your skin there is a pull tab that cleanly, quickly, and simply exposes the back half. A breeze to stick on. And it sticks really well. Like an infusion set, once in, you pull out the guide needle that you used to insert. That leaves just the flexible probe inside of you. They look a little more substantial than the Teflon cannaula of an infusion set, but I don’t feel a thing. You can insert manually like I did, and will probably continue to do; or you can use the inserter. Looks well designed, and I think it will be easier for most folks to go that route. So the sensor’s job is to measure the glucose in your I.F., and send that information to the transmitter.

The transmitter looks like one of those things you use to open your car as you walk up to it. Do those actually have a name? I suppose they do, but I don’t know what it is. When I first saw the transmitter I was appalled. It looked so big. I’m going to have to wear that on my body 24-7 for the rest of my life? You gotta be kidding! It seemed, big, heavy, and thick. I was thinking, I’ll never be able to wear a tight shirt again. Women are going to ask me, “is that a Guardian transmitter in your pocket, or are you just happy to see me?” I thought, this thing is gonna wake me up at night if I roll over on it.

Don’t panic.

In fact, in real life use it is no bother at all and I don’t even know it is there. The actual size is about two inches long, inch and a half wide, and a little over a quarter of an inch thick. It has a short wire that plugs into the sensor. It is slightly tear-dropped shaped and is held on to your skin using a really nifty tape. The tape is a thin foam pad. Same shape as the transmitter and slightly larger. You affix the tape to the back of the transmitter, then stick it on your body. It must breath a little bit, because it is very comfortable. Stays on really well too.

The transmitter, according to the manual, “receives and process signals from the sensor, and it sends the signals by radio frequency to the monitor.” It is a totally sealed unit. All you do is put it on. Everything is controlled from the monitor. Because the transmitter is sealed up, to make it water proof I assume, the batteries can not be changed. Just like the first generation I-Pod, when the batteries die, you gotta buy a new one. $400. Once per year.

The monitor looks like a garage door opener. Or maybe a pager. Not sexy or flashy, but conformingly beautiful in a no-nonsense utilitarian kinda way. The size is three and one-half inches top to bottom, two and a half inches side to side and about an inch thick. First impression here is too big too. But once you are wearing it, it takes up surprisingly little room. Of course you don’t have to wear it. It is wireless. I chose to wear it because that works with my life style and wardrobe. But you could carry it in a brief case or purse.

Five buttons control everything. Actually, in point of fact, four buttons control everything because one button is the on and off button and I can’t imagine a situation in which I’d turn it off. There are two arrow buttons, one up and one down. They are in the center of the monitor. On the left is a button called “Sel,” which stands for “select.” You use it to navigate among the different screens. On the left is a button called “Act,” which stands for “activate.”

Using one or more of the buttons in various combos lets you program, control, and respond to the monitor. Sounds worse than it is. In fact, I’ve found the systems to be well thought out and very intuitive. This is not a hard machine to learn at all, and in the next few days I’ll start digging into details of operational use.

There is a nice little leather case too. It has been well engineered so that the heavy duty belt clip on the back on the monitor is still used (the clip is removable). There is a clear vinyl window that covers the controls and view screen, covered by a flap with a Velcro tab. When you are wearing it, it becomes a inoffensive little black box on your belt. Won’t arouse any attention at all. When you want to check your sugar, slip it off, open the flap (which I can do one-handed) and press “Sel.” That gives you your sugar at this very moment. Mine is 111, thank you for asking. What’s yours? Well, while you are looking for your test strips, meter, and lancet, I’m going to go check on the Turkey.

I haven’t used the computer dock yet, I wanted to wait until I actually have a couple of days of data to look at, so I’ll review that and the software in a future post. A quick story to close with. I had to drive down to Albuquerque last night (never mind why, if I go into that story this post will become a novel).

When I jump into a car I’m in the habit of checking my sugar, assuming I’m the driver that is. So last night I just flipped open my case....I didn’t even need to take the Guardian off my belt. I pressed the “Sel” button and looked down. We were good to go.

Coming down Terijas Canyon on I-40 my pump started buzzing. It had been two hours since my last bolus. I’m sure you all know about Interstate BG checks. Do you pull off the highway and risk getting creamed by a semi truck that wanders briefly on the shoulder? Or do you balance your pump on top of the steering wheel, the infusion set hose not quite reaching while you hold your lancet in your teeth, opening the vial of test strips one handed, dumping half of them on to the floor....Did I mention that this is after dark?

But this time it was so easy. I cancelled the pump alarm by feel. Slipped the Guardian off of my belt one-handed, flipped open the case with my thumb. Pressed the down arrow to turn on the back light...greenish blue...and pressed the Sel button. She displayed my “Now” BG. How cool (and safe!) is that?

$2700 machine
$ 40 sensor
$ 26 in gasoline
Driving without fear of hypoglycemia? Priceless.

Happy Thanksgiving everyone!

Wednesday, November 23, 2005

A good day

What's my blood sugar, you ask? I don't know. Let me check. Click. 139. I just love doing that! No finger stick. No fumbling with meters and cases. No waiting at all, just one simple click of a button and I know what my blood sugar is. This is soooooo cool.

I had a real good day at the shop today. I spent almost the entire day working on 16x20 inch fibre prints for a customer in Amman, Jordan. Fibre paper has to be tray processed by hand, the old fashioned way. You work bathed in yellow-gold safelight, about as bright as the full moon. Water flows, gurgles, burbles...hydraulic acoustics that sooth the soul. I've got Bach playing. One-by-one in the developer tray the images slowly form. First the paper is white, then as the developer slides across the surface of the print the blacks begin to appear. Dull gray at first, then darker, darker. Blacks taking shape, grays and whites begin to reveal themselves. Over three minutes the blank sheet becomes a stunning, vibrant, rich photograph. I’ve been doing this since I was a kid, but it is a magic process that I never tire of watching.

You're probably saying, "Damn it, Printcrafter, shut-up and get on with telling us about the Guardian!" Well, there is a point here. Fibre printing takes a lot of concentration. It is very hard, exacting work that requires attention to detail. For the last six weeks I've hated doing it. Too many worries on my mind.

But today I didn't have to worry about my blood sugar. That is so important, I'm going to say it again. Today I didn't have to worry about my blood sugar. The Guardian is worrying about it for me. If it goes too high she‘ll tell me. If it goes too low she'll tell me. So today I could focus my mind on my work, not on my diabetes. What a gift!

I wanted to give you a preview of upcoming posts. I'm going to be playing around with the software and the computer dock in the next few days. I'm also going to take you through a complete site change. I want to talk more about the transmitter, and what it is like wearing it. I want to talk to you about what it is like wearing both a pump and a Guardian. I want to tell you how the Guardian tracks my insulin and my carbs. I want to show you how you can customize it. So much to tell!

Not to worry, we‘ll get through all of it. I’m taking a trip to Denver to visit my Mom this weekend, so I’ll have reports on traveling with it too.

Well, gotta go for now. A darkroom timer is beeping at me. Time to take prints out of the washer!


Baaareeeroooo.....Baaareeeroooo.....Baaareeeroooo.....Baaareeeroooo.....The frantic alarm splits the night. My eyes snap open. 3:23 a.m. Wha..??? What's that? An eerie, frantic, descending, corkscrewing noise...Flying saucers from Mars landing on my roof? Screaming, whistling fireworks descending from the inky sky on the forth of July? is the Guardian. I frantically fumble for it in the dark, my fingers blindly, dumbly seeking out the unfamiliar buttons. Need to get her quiet before she wakes up the whole crew!

I finally find the right sequence and silence descends. The only sounds the rhythmic breathing of the wife and child. Whew! I open the case and hold the screen near my nose, where I can read it without my glasses: Glucose LOW.

The first night on the job and the Guardian has caught a hypo, alerted me, and let me nip it in the bud. We are going to have a lot to be Thankful for this Thanksgiving Day.

Tuesday, November 22, 2005

The Guardian Speaks

Whoa! What was that?! It sounded like a cross between an air-raid siren and a winning hand on my wife’s hand-held poker game. My belt is vibrating too. Ah, the Guardian speaks... I forgot to mention you can set it for noise, vibrate, or both. Naturally, being a guy who wants it all I chose booth. (Seriously, I prefer vibrate... but at night I want a noise to wake me up. It’s crowded enough in bed with the pump, the wife, and sometimes the kid. The Guardian will just have to sleep on the night stand by herself.)

I slip the little beauty off my belt to see what all the ruckus is about. A high BG alarm! My first alarm! It really works!!! I’ve been hooked up less than eight hours and it’s already intercepted a problem!

BG 202, she tells me. I confirm with a finger stick using the CoZmonitor. It calls the game at 209. Damn, that’s really good. They are very, very close. Medtronic sure has a winner with this system! I take a 0.55 unit correction, reduced for IOB (insulin on board--Cozmo speak). I set the snooze alarm for one hour. A snooze alarm? you ask. Yes, another clever gift from the Medtronic engineers. There is snooze alarm option on high BGs. Why? Well, it takes time to fix a high. You don’t want your Guardian squawking at you every five minutes while you are trying to come back down, now do you?

Hook up

What is my blood sugar you ask? Well I don't know, let me check. Click. 172 right now. What was it five minutes ago you ask? Let me check. Click. Also 172. I can scroll backwards in time five minutes per button click. Pretty nifty. With another click I can switch to 30 minutes slices of life instead of five minute slices. Thirty minutes ago I was at 150. An hour ago at 148. An hour and a half ago at 129. OK, the numbers are nothing to be proud of, but the technology is pretty impressive!

In fact there are a lot of nifty things about my new Guardian...way to many to cover all of them tonight. Yes, it did come. By noon I had panicked and called Medtronic. Turns out they recently switched to UPS as a shipper but my contact there was still in the habit of saying FedEx. No problem, I put away my FedEx Truck Voodoo Doll and scanned the horizon for my friendly local UPS man.

He came early, for UPS, with two big boxes. The larger of the two was like one of those gag gifts with consecutively smaller boxes inside of each other. This was the cool pack. Three inches of white Styrofoam. Two large frozen gel packs. At the center of a box that was more than a foot on each side are ten tiny sacks of sensors. Still plenty cool. Straight to the fridge with them. Before anyone panics, they only need to be kept cool prior to use. Just like your insulin vials. They are actually OK to be at room temp for a week, so if you are taking a short trip you can take your next site change with you without worrying about packing ice.

The other box has my equipment. I've been trained and briefed, but I restrain myself and read through the manuals and paper work before hooking up.

This is the hard call for me: insert by hand or use the inserter? I tried an inserter during my training, didn’t hurt me a bit, but it bled like hell. Maybe my angle was wrong, maybe I didn’t pinch enough fat. Who knows? But now I’ve only got ten of these things....I’m used to Smith’s who send me three months of infusion sets at a time. They always seem in abundant supply. Ten sets seems like such a small inventory. I must protect my stash!

The needle is shorter than the Comfort set’s, but easily twice as fat. I decide to try doing it manually first. If I can’t get it in, or if it is too painful, I can always wuss out and use the inserter. I gather up my supplies. The monitor is filled with batteries, programmed and standing by. My infusion set is on my left side, so the right side is designated as my Guardian side. Don’t want all the holes to be on one side.

I wipe the area with alcohol. No IV Prep--it messes up the readings apparently. I grab a pinch of skin, hold the guide needle to the target, take a breath, and....

(You winced, didn’t you?)

I push slow and steady, increasing the pressure bit by bit. More and more. The skin presses down under the tip of the needle, but the needle doesn’t slip through the skin. No major pain yet, but I’m not sure this is going to work..... and then the tip of the fat needle pierces my skin and I smoothly slide it all the way in to the hilt. Took quite a bit more “elbow grease” than I’m used to. But it is in. I’m feeling no pain. No blood.

Next I tape the transmitter to my stomach above the set. I initialize the Guardian, set it to search for the signal, and then I plug the transmitter into the set. In an instant she displays “Success.” We have telemetry. The transmitter and the monitor are talking to each other wirelessly. It will take another two hours to initilaze the sensor, then the sensor and transmitter will feed near constant updates about the status of my blood sugar to the monitor for the next three days.

Day one

9 o'clock. No FedEx.

10 o'clock. No FedEx.

11 o'clock, No FedEx.

I'm trying to get some work done, with no success. Did I hear a noise? Is FedEx here? I look out the window. No, must be the wind.

Trying again to work. Did I hear a noise? I look out the window. No, just a plane flying over head.

Trying to work. Did I hear a noise? I look out the window. No, nothing but a rabbit in the parking lot. This is getting ridiculous.

I had hoped my FedEx guy would come early. He's usually here around 9or 9:30....but sometimes he doesn’t come until nearly five. I figured I’d spend most of the morning "hooking up;" and then try to get some real work done later in the day....

Did I hear a noise?

Dollar, cents, and delivery (a.k.a. Day One minus one...)

Hooray! I just got a phone call from Medtronic. My Guardian ships out today and will be in my hot little hands tomorrow. Shipping has to be coordinated as the "sensors" need to be kept refrigerated. In fact, my rep tells me that the shipping container has a temperature warning indicator. Some sort of LCD thing, haven't seen it yet so the details are a little sketchy. Bottom line all the way around: if it gets to hot in shipment this will show it. Bottom line for FedEx: they gotta get it to you pronto (a trick here in New Mexico where first thing in the morning delivery means before sunset...). Bottom line for us: open the damn box as soon as you get it, and get those gold nuggets in the fridge!

The little SOB's cost $40 each. They look like an infusion set, but don't kid yourself. These puppies have as much in common with an infusion set at the Wright Flyer does with the Space Shuttle. Ya stick both under the skin, but that is where the similarity stops. The sensors are high tech stuff. Among other exotic elements used in the construction: platinum. I know some diabetics who cry when they mess up putting in an infusion set and have to redo. How would you feel if you dropped a $40 sensor in the toilet?

Speaking of dollars, let’s talk about the cost of the system. The basic system, which includes the monitor, transmitter, computer dock, software, and your first month’s worth of sensors costs $2,790. So roughly half the cost of a pump.

You wear a sensor for three days. If you wear 24-7 they reckon you use 10 per month. As I mentioned before they run forty bucks a pop, so your consumables will cost you $400 per month. The transmitter lasts for a year and then needs to be replaced at the cost of another $400. The sensor and the seam between the transmitter cable and the sensor need to be covered with an IV3000 patch to keep them water proofed. (Don’t worry, I’ll upload photos of all of this later). I’m not sure if MiniMed users are familiar with the IV3000. Smith’s sends them to us Cozmo users. In theory, you put one on your skin under your infusion set. In practice, most Cozmo users don’t bother. In fact, I just sold my first (virtually unused) box of IV3000’s on Ebay. Oh well, who knew?

The IV3000 is a very, very, very thin skin-like bandage. I don’t know yet what those are going to cost, but you need to add it to your tab. The bottom line: this is not a cheep system. But we all know that diabetes ain’t cheep! Am I filthy rich? I wish. This system is going to require some big sacrifices in our family budget. Hopefully, within the year the insurance companies will get on board. But my view? Funerals aren’t cheep either. If it keeps me: One, alive; and two: healthy; then it is a bargain.

Sunday, November 20, 2005

Meeting the machine...

I’m in the spacious two-story lobby of the LaQuinta on highway 71 in Austin, Texas. I’m finally holding the holy grail in my own two hands. Of course, this one isn’t mine to keep. This is the rep’s demo unit I’m training on. First impressions. I’m holding the monitor. It is well built, about the size of a pager. Thick. Really nice belt clip--heavy duty, not one of those wimpy little things that will break easily. Some will complain about the size of the monitor, I’m sure. It’s bigger than my pump, but not by much. As a direct descendent of the CMS Gold system that was used in doctor’s offices, Medtronic has not redesigned the case or computer dock (which looks like something AT&T might have manufactured in the 1970’s). “But the software is state of the art,” the rep anxiously assures me. I don’t care, I think it is beautiful. Like my pump, I doubt anyone will ever notice it or ask about it. Sigh...

A note to you MiniMed pumpers: the real goal of the company is to integrate the Guardian with a pump so you’d have only one item on your belt or in your bra. For the rest of us, no big deal. Now I’ll carry a cute little box on my belt instead of a case with test strips and lancet. (Of course, being wireless you could keep it in a purse or brief case, pocket, whatever.)

The sensor is smaller than my infusion set, but a similar design. There is an inserter, which is pretty slick or you can insert manually. Rather than a hose, you plug in a short wire that leads to a transmitter. The transmitter is about the size of the average wrist watch, and equally thick. If you are wearing tight fitting clothing it will show. There is a sticky pad that holds the transmitter onto your skin. By the way, the batteries in the transmitter cannot be replaced (water proof sealed unit so you can shower with it) so the entire transmitter must be replaced each year at the cost of about 400 bucks. To their credit Medtronic was very up-front about this extra cost. We spend about two hours talking about the system, but you could probably be trained in 15 minutes. It is simple. I can’t wait to get started! Hopefully they’ll ship my Guardian out on Monday for FedEx delivery on Tuesday. Stay tuned...

Saturday, November 19, 2005

Meeting the Texas Doc...

I really didn’t know what to expect. Was this just a rubber stamp visit? Was it a glorified pay-off for signing a script? Or was this going to be a real doctor’s visit? Frankly, I didn’t much care which way the cards fell at this point. The office was a do I want to say this? Well, it looked a bit low rent. As did the other patients. As did the staff. Never read a book by its cover. Once I was past the waiting room and into the inner sanctum I walked down a hall of certificates and awards. Phi Beta Kappa. Hmmmm....

The Doc spent a lonnnnnng time with me. More than an hour. I liked him. He was interested in my case, intelligent, insightful and through. He studied where I was before and where I was now. He inspected me up and down. His Dx: I was a good candidate for the Guardian. It would be good for both for me and for Medtronic. “...and you’ll use it,” he said. Who wouldn’t? He faxed the prescription.

The unexpected bonus: he took copious notes for a letter he was going to write to Blue Cross and Blue Shield telling them why, in his words “they should pay for it for you.” The first salvo in a battle I don’t personally expect to win. But important none the less. Eventually the avalanche of paper and the logic that healthy diabetics are cheaper for everyone one in the long run will turn the tide. Hopefully many of you will be able to get Guardians paid for by insurance. I’m OK with being of the edge of the envelope. I’m OK being a trail blazer. I benefit from this too, after all.

Thursday, November 17, 2005

The odyssey....

Well, I don’t want to bore you too much, dear I’ll try to condense. You can see I suffer from “bucket fingers.” Same thing happens when I’m talking. I just don’t know how to shut up! Well, you just gotta be true to how God made you...

The short version is that I called Medtronic and said “I’m holding a credit card in my hand and I want to buy a Guardian. Tell me what to do.” And they said, “If you know your party’s extension you can dial it now...”

After be transferred around a bit I ended up chatting with the woman at the corperate level who is in charge of the Guardian roll out. The bottom line was that you need a presription and it must be written by a Doc in one of the seven cities. They didn’t have a problem with the fact I was out-of-state from those locations, as long as I was willing to travel in for the Doc’s apointiment and training. I was. Pick your city, I was told.

Oddly, or so it seemed at the time (there really is a reason, but more on that later), three of the seven cities are in Texas. Texas isn’t that far from New Mexico... I went to Southwest Airlines’ web site and searched out airfares and flight times to the three cites. Austin was the winner in speed and price. I called Medtronic back. Austin. They put me in touch with their rep in Austin. I explained my situation...predicament? her. In the past 30 days I’d had to intervene to prevent hypos 15 times. The other 15 days were text book. The food and carbs were similar. I was a nervous wreck. I was testing every 30 minutes after every meal for four hours. I worried about hypos at night while I slept. Will I wake up tomorrow? I felt like a human time bomb. My fingers look like a human pin-cushion. I wanted the Guardian and I wanted it today.

But with the medical community, nothing moves that fast. To her credit, she got me an appointment with an Endo in Austin within two weeks of my call, and she did it in three days. At the time is seemed an eternity, but in hindsight....Well, she rocks! Hell, I can’t get in to see my own Endo that fast....

Then the spider web of Federal and State laws set in. Medtronic can’t ship a Guardian without a prescription. FDA rule. That means, for all practical purposes, it is carved in stone by the hand of God himself. Medtronic isn’t going to screw with the FDA. Texas won’t let a Doc write a prescription without first meeting the patient. A sensible law, we can all agree. But the net result was there was no way to get my machine in advance of my visit so that I could be “hooked up.” They couldn’t send it to me, to the Doc or to the Rep. In then end the solution was this: I’d fly to Texas. The Doc would look me over and if he agreed that I was a good candidate he’d write the prescription. I’d then train with the rep on a demo unit. Once Medtronic had the prescription in hand they’d ship my machine and I’d hook myself up. I placed the order on Thursday. Flew to Austin Friday. It actually took me longer to drive from my house to the airport in Albuquerque than it did to fly from Albuquerque to Austin! I met with the Doc on Friday and the local rep on Saturday.

Tuesday, November 15, 2005

Day 1 minus three weeks....

My CoZmo pump vibrated more quickly than usual. A sure sign that the sugar reading would be low. I glanced down calmly expecting it to be in the high sixties. It was 35. I stared at it dumbfounded. The only thing my brain could process was: I should be unconscious.

I felt fine. No elevator dropping beneath my feet. No cold-clammy sweats. No shaking hands. I should be unconscious. No blinding head ache. No cloudy thoughts. Must be a bad reading.
I re-check. Now 34. I should be unconscious. “Babe,” I call out to my wife, trying to keep my voice very, very calm as I reach for my emergency candy. “You know where my Glucagon Emergency Kit is, right?” I should be unconscious.

That was the moment I decided to buy a Guardian RT.

What is the Guardian?

First some back ground on the Guardian. Approved by the FDA in August, Medtronic’s newest coup is a true continuous glucose monitor. We’ll dig into even the tiniest detail of the system later on, but in a nut shell you wear an infusion-set-like sensor that is attached to a small transmitter that is taped onto your body. The transmitter wirelessly sends data to a pager sized monitor that can be up to six feet away.

The Guardian checks your BG every five minutes and alerts you if you are high or low. If I had been wearing a Guardian three weeks ago I would never have had a BG of 35. I would have been warned when I went below 80. I would have intervened earlier. I would not have scared the shit out of myself and my wife.

If that weren’t reason enough to own a Guardian, the icing on the cake is the data. Wearing a Guardian you have access to the entire continuum of your sugar readings. You can see the exact pattern of your sugars over a day, a week, a month. You can see exactly what that Pizza did to you. With finger sticks you can only guess were your sugars are between checks. You go to bed at 114. You wake up and 109. But where were you at 2 am? Now you can know. Now you can fine tune your basal rates and boluses to a degree unimaginable a few years ago. They finally made a crystal ball that really works. Welcome to the magical world of high-tech!

So why wouldn’t every diabetic want to own one? Price of course. FDA approval doesn’t grant insurance coverage. Everyone at Medtronic assures me that getting the insurance companies on board is job #1. Availability is another issue. Medtronic has only rolled out the Guardian in seven cities in the United States. So you gotta pay for it, and you gotta live in one of those cites. Or you gotta do what I did. My mother paid for it and I took a trip on an airplane...

When I first went looking for info on the Guardian I could find precious little except from the manufacturer or from sites that ran the Medtronic press release. That didn’t stop me, my mind was made up. But it would have been nice to know more. As it turns out I’ll one of the first 50 diabetics wearing and using the Guardian in the real world. Now I’ve got a place to tell you the good, the bad, and the ugly. So stick with me as the adventure unfolds.....

Copyright 2005 by William Dubois