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!).

Friday, July 28, 2006

Ripped from the headlines

Water drips, drips, drips, drips from a pipe high above in the hallway; pooling in the darkness outside the cell door. Cool wet air whistles into the cell through the cracks around the bared windows. The cold makes the prisoner's bones ache. So unlike the dry hot air of his homeland.

With a clank and a thud the door swings open, rusty hinges shrieking. Five men crowd into the cell. Three burley uniformed guards, the small jumpy translator, and a new man. A man in a suit. CIA? He holds a small box.

Once again, the questions start. "Where is Osama?" demands the translator in passable Arabic. It has a strange accent. The prisoner had never been able to place it. The prisoner spits on the floor.

The man in the suit makes a subtle hand gesture. The guards advance and pin the prisoner to the wall. The man in the suit opens the box and takes out a small black device. He gives it to one of the guards. "You'll talk," he says with a wicked smile as it is strapped onto the prisoner's arm.

At first the prisoner feels nothing. Then an odd sensation. First a tingling. Not quite an itch. Not quite a burning. Sort of a tingly-itchy-burning sensation. It grows in intensity. It becomes alarmingly painful, the prisoner tugs at the device but aggressive glue and straps hold it firmly on his arm. As the pain reaches it's crescendo, it stops.

The door squeals and slams shut, and the prisoner is alone again. About five minutes later the tingling starts again. Then the burning sensation. Right as it feels like needles being spun into his skin it stops. Then five minutes later it starts again.

Within three hours the prisoner’s mind is filled with dread. When he's not experiencing the pain he's anticipating it. The pain is not really that dreadful, but the incessant nature of it preys on the mind, like the drip, drip, drip, drip of the water from the pipes in the ceiling of the hallway out side his cell door.

After two days he breaks and screams for the guards: "Ok, Ok, I'll tell you where Osama is, in the name of Allah, just please remove the device, I beg you!"

Three months later: in the Washington Post It Newspaper:

Administration officials today denied the torturing an enemy combatant at a secret prison in Eastern Germany earlier this year. The New York Times and the AP report that a senior Al Qaeda operative was interrogated by attaching an electrical device to his arm and applying electrical shocks every five minutes. CIA Spokesman Chris Liealot denied the device was a torture instrument, but rather an FDA approved medical device commonly used by diabetics in this country to monitor blood sugar levels. "We are firmly dedicated to the health and well being of enemy combatants in United States custody," said Liealot, "and that includes the monitoring of blood sugar in suspected diabetics." The prisoner’s arms were reportedly burned in multiple places. When the manufacture of the device was contacted, they confirmed that the device will cause "mild to moderate" skin irritation in most individuals.

Welcome to the GlucoWatch. By the way, Bin Laden was on the 14th floor of the Plaza Hotel in New York City (hey, people tend to forget the guy is a millionaire) ....but he had just cleared out when the SWAT team stormed the hotel.


Wednesday, July 26, 2006

Day planner Disaster

6am: alarm goes off. Become ambulatory with great effort. Not a morning person by nature or nurture. Bush teeth. Shave. Shower. Change infusion set and pump battery. Dress, turn on coffee pot, quick breakfast.

7am: depart for work.

8pm: arrive at clinic. Hectic work day. 30 minutes for lunch. The rest of the day a frantic, but interesting blur.

6pm: leave work.

Drive to Sam's club for one little thing. Hmmmmm.....gas in Santa Fe only $3.04 a gallon. Whatthefuck did I just say? They've got me so numb to high gas prices that I'm actually thinking three bucks a gallon is a deal. At one end of my commute it is $3.14 and at the other $3.19

One little thing at Sam’s turns into $98.97, of course.

Rendezvous with Deb and Rio for dinner. Slow but fun. Depart Santa Fe at 9:30 pm. Rain slows down the trip home. We've been so desperately dry I don't care.

11pm: arrive home. Make coffee, lay-out clothes, weigh breakfast cereal for tomorrow. Find stuff for sensor change.

11:30pm: Deb and Rio arrive home, bringing the rain with them. In tennis shoes and underwear, carrying umbrella, I dash out to rescue the sleeping child. Strong wind leaves me soaked to skin and wakes up said child.

Midnight: collapse into bed.

FOOT CRAMPS!!!!!!!!! Charley-horse level pain. Every toe and the entire top of foot. Rubbing no help. Take calcium, vitamin E, valium, and Advil. No luck. I end up standing on toes, head leaning against wall.

12:3am: back to bed.

3am: woken by crying child. Hot. Needs water.

3:15am: return to bed

6am: alarm goes off. Become ambulatory with great effort. Not a morning person by nature or nurture...........

Sorry I haven't been posting. 40 hours a week at clinic. 30 hours per week at lab. Not much time at the moment...But I promise to carve out a few minutes soon!

Saturday, July 15, 2006

No room for macho

Buzzzzzzzip. Buzzzzzzzip. Buzzzzzzzip.

I'm using my trusty Norelco that I bought at Wal-Mart. Once again, I'm shaving a part of my body that I never anticipated shaving. I've had a beard most of my life. I use a Braun razor to trim the cheek bones and my neck. But when I started pumping I needed to shave the skin on my stomach. For that the Braun was no good. Too much surface area. So I bought the Norelco with it's three whirring little heads.

When I started using the Girl I shaved the top of my legs. I'm not a gorilla, mind you, but it doesn't take much hair to screw up these sticky things. And we won't even talk about the pain of pulling the sticky things off of hair. We men are weenies when it comes to waxing. Don't know how the ladies do it....

Now I'm shaving the inside (bottom side?) of my forearms. The thin, willowy hair comes right off. No trouble. But the skin tingles and burns a bit. From past experience I know that skin that has never been exposed to the razor does not care for the experience the first few times. That's why I'm getting a jump start on my next tech project. Give the skin a chance to get used to the razor and the air before the new toy gets attached.

So what is the new toy? Well, that requires us to take a step back in time. Actually it was earlier in the day of a previous post. The one about inhaled insulin. When you don’t post every day you sometimes have to be creative with how you organize your posts. That was quite a day. I did some lab work in the morning, then visited with the new CDE at my endo’s office, then went to Trader Joe’s, Albertson’s, Wal-Mart, Sam’s Club, and Starbucks. Can you guess which places I visited with a list from my wife, and which place I went to on my own accord? Then it was off to Albuquerque to hear about Exhubera.

So what’s up with the new CDE, you ask? Well the old one, who I dearly loved (and who was directly responsible for my getting my new job--more on that in a future post, as I keep promising) met a guy. Well, THE guy, as it turned out. Actually she met the guy on-line. Match dot com? I’m not sure if that was the one, but one of those kinds of places. What do I know about these things? I’ve been married forevvvvvvver. Happily. Of course.

So she met this guy, who is a Chef. Long story short: she fell in love. Got engaged. Planed to move. Tempted me with her job. Got wet feet. Took job away again. Almost called wedding off. Recovered senses. Married Chef. Moved away. In all the confusion someone else got her job. She made it up to me by finding me my current job. Everyone lives happily ever after. At least her, the Chef, and me. But not as one weird family or anything like that.

As is typical, I’ve wandered off here. It would probably completely destroy my writing style if I ever got more than six hours of sleep. So the point was I was meeting the new CDE. We were sitting in her office chatting when two boxes on her book shelf caught my eye. They said.....well, now that’s going to spoil the surprise, isn’t it?

Let me back up a minute. What do all of you think my new toy is?

I'll bet some of you put your money on a sensor augmented pump. Wrong. Sorry. Blue Cross won't buy me a new pump for....three years? then there will be several to choose from.

Some of you probably put your money on a DexCom. Nope. Sorry, wrong again. Not that I wouldn't want to try one. Not that I didn't write and request a review copy (they never responded). I might have one in the next month or two anyway, however. My buddies in the big city have a practice that is buying a half dozen with the plan to rent them out to patients to help fine tune and/or test drive. It might be possible for me to wear one for a month at the same time I’m wearing the Girl to compare. How's that for exciting?

Many of you are praying I've some how got my paws on an advance unit of the Navigator. Again, sorry. No. But I do know of a CDE who's going out to be trained on it. Lucky dog.

No the boxes that caught my eye said: GlucoWatch G-2. Now I thought I had read that there was a second generation of this much-maligned machine on the market. So I asked CDE 2, “so what do you think of the new GlucoWatch?”

She shrugged and told me she didn’t know. They didn’t have any patients on it yet, and she wasn’t even quite sure where they‘d come from. Did I want one?

I’m not good a turning down free stuff.

Now the original GlucoWatch was a ground breaking disappointment that almost everyone universally hated. It was the first continuous glucose monitor and the first non-invasive glucose monitor. It was called inaccurate and it burned some people’s skins. Seems everyone hated it and I thought I’d heard that the company that invented it went under.

I’d recently seen ads in the back of the ADA magazine pushing it, or a new version of it, again.
So I snagged it. I was so tickled that someone gave me an $800 piece of equipment that I ordered a box of sensors before doing proper due diligence. Stupid me. Well, maybe stupid. Maybe not. We’ll see.

Anyway, it turns out that Animas (the pump company) now owns the GlucoWatch. And it also turns out that it is the same old much-hated watch. The original GlucoWatch was called G-2. I guess what I had read was the Animas had bought it. When I saw the “2” I mistakenly assumed there was a new generation. Not so.

Well, I’d already ordered sensors by the time I realized my mistake. So seventy bucks down the drain. But then I got to thinking.

When I first had the Guardian I had a lot of disappointments. And it is actually a fine device. One I would not want to live without. One whose weaknesses I can live with. One whose personality I now understand.

And that got me to wondering. Was the GlucoWatch really bad? Or did it suffer from merely not living up to people’s expectations for it? We now all understand the limits of continuous monitors, whether Guardian or DexCom. But back then, we all expected a silver bullet. A magical device that was 100% accurate and read 100% of the time. We now know that isn’t the way it is. But even so, we find great value in the systems.

So was the GW unfairly maligned or is it really a piece of crap? CGM is not what we had hoped it would be, but it is damn useful. From our new perspective will the first to market prove to have a use after all? Animas must think so. They’ve bought it and aren’t afraid to associated their name with it.

So I'm going to wear it for at least a couple of weeks and compare the data to the Guardian and to finger sticks as well. Come on, it'll be a fun science experiment! Repeat after me: science is fun, science is fun, science is fun....

So I take the my GW out of the box to try it on. Just to see what it will look like.

Buck Rogers. Dick Tracy. James Bond. And me. Oh yeah.

What do these four manly-men have in common? Other than smashing good looks and incredible intelligence? That's right, all four of us are Type-1 Diabetics. (Yeah, I know, James tries to hide it. That tiny little insulin pump Q made takes a sharp eye to spot.)

And we all four wear cool tech on our wrists.

Wednesday, July 12, 2006

The best laid plans....

My plan was for this post to be titled: 233 days of Guardian. That's what today is. My 233rd day. I was planning to share all kinds of new tips and tricks I've learned while I was on sabbatical. I've got a bunch of them. I'm also all alone in Albuquerque; having been sent here by my clinic for three days of Medicaid training. Yes, it is every bit as boring as it sounds.

As hookers are not in my budget right now, my plan was to spend my nights catching up on my blogging.

Well sorry folks, but that's not going to happen. And it's nothing to do with hookers....

It has to do with an 8-year-old boy. Because of HIPPA rules and regs I can't tell you his name. His Grandmother is one of my patients. And she decided to test her grandson with her meter. The boy clocked a 234. Fasting. Yeah. That would have been enough for a Dx if it had happened at the clinic.

The boy's mother came to me in a panic. I quickly scrambled the schedule and told her to bring the boy in. Right. Now.

Here's the story: he tells me that no matter how much he drinks, he is always thirsty. He's peeing all the time. The mother tells me he's even started wetting the bed. He's become moody. Grumpy. Doesn't like to play with other kids anymore.

I do a random BG on him and he clocks in at 144. This is one hour after eating a slice of pizza. I run an A1C in our lab and get a 4.9

Hmmmm.....Whatever is going on, it just started.

The kid is fat, but not HUGE. But he is not active at all. I set them up with a meter and instructions to test every AM and come back on Monday. I'll run C-peptide and islet cell anti-bodies, but he just doesn't feel like a Type-1. I'm thinking he might be our first case of juvenile Type-2. I knew this was a growing problem in our country. I knew we'd have one sooner or later. I just didn't expect one quite so young.

As all this was happening the good folks at Bayer brought me 48 glucometers for our patients (thank you good folks at Bayer). So I was making room for them in my office by throwing out old phone books, out dated PDRs, software on 5 inch discs, and other debris left on the book shelf by the previous occupant of my office. As I was quickly “editing” the contents of the book shelf, a thin little red book fell out and landed on the floor at my feet. Not a finger print on its glossy cover. Never been read. The title is: Type 2 Diabetes in Children & Adolescents. A guide to diagnosis, epidemiology, pathogenesis, prevention, and treatment. From the ADA. And only a few years old. Much newer than the phone books I just threw away.

So instead of filling you in on my new Guardian knowledge, I am instead filling my head with knowledge to help my youngest patient.

I know that you of you will all understand.

Sunday, July 09, 2006

Will huffing and puffing blow the house down?

I had seen pictures of it, of course. We all have. But now I held one in my very own hands. Was this the future of insulin delivery? Or the biggest flop since the Edsel? It is not as big in person as it looks in the pictures on the web and in the trade journals. Not until you expand it, at least. Then it looks more like a police baton than an insulin delivery device. And, as been pointed out by others, a bit more "bong" like than I'd personally care to be seen puffing in public.

I'm at a swank dinner in Albuquerque hosted by the good folks at Pfizer. I'm actually in a room full of Pharmacists due to a series of bizarre email and miscommunication problems. That's OK. I like Pharmacists just fine. But I was the only Diabetes Educator there. Oops! I let the cat out of the bag about my new job, didn't I? Well, more on that later. It probably deserves a post of its own.

We are about two weeks before the roll out of Exhubera, the first FDA approved inhaled insulin and Pfizer is both trying to drum up excitement and get the Docs, Pharmacists, and Educators up to speed on how to prescribe, dose, train, and all of that kind of stuff.

Actually, if the inhaler had been a snake it would have bit me. I was sitting at the table, yakking with some of the other attendees, and eyeing a real life inhaler that was sitting on the projector table in the center of the room.

As I reach for my ice tea goblet my hand hesitates. Right there. Two inches from my tea, is an actual Exhubera inhaler sitting innocently on the table in front of me. I could have snitched it and put it in my pocket. It would have made a fine trophy. I tried to wrangle one later, with no luck. They are under lock and key until the official release date. I wanted to put it on my desk with my Byetta Pen, OptiClik, and Novo Training pens. Well, I'll have one in a few weeks....

I play with it for about ten minutes before mastering all of its buttons. It is clever and well engineered but there is no shortage of ways the user can get confused. You slip your finger into a ring at the bottom and pull the handle out of the mixing chamber with a satisfying shuuuunk! A little pouch full of dry human insulin the size of a Pepcid AC slides into the drawer. You pull open the handle, reveling a syringe-like air plunger. Snap the handle closed to pressurize the unit. Squeeze the trigger, and you are supposed to see the insulin powder fly into the clear chamber. Of course the training packets are empty. Couldn't they have filled them with some sort of inert powder for visual effect? We are forced to use our imaginations. The patient would then swivel the mouth guard around, make a seal with their lips around it and inhale deeply.....wait five seconds....and then you'd think your done, huh? Wrong!

Depending on your weight, you may need to do this three more times for a single meal dose. Hmmmmm.....I'm not thinking most of us are going to be too enthusiastic about this....

The device is less than discrete. And you have to load, cock, twist, and suck on it four times? Oh yeah. And the waiter better not be slow. You got 10 minutes to start eating. Fast on-set. On the back end the tail stretches out. Hypo territory is at the four hour mark.

One thing that troubles me is that the insulin delivery is based on the patient’s weight, not the amount of carbs in the meal. Whatthefuck? How is that supposed to work? The 200 pound guy who is eating barbeque ribs, potato salad, apple sauce with cinnamon sugar, and pecan pie with vanilla ice cream is supposed to take the same amount of insulin as the 200 pound guy eating a chef’s salad? Printcrafter's stock tip of the week: sell Pfizer.

I salute them for trying something new, but I don't see this working out. It also looks like they are pricing themselves quite a bit higher than liquid insulin. I don't see insurance companies forking out for inhaled insulin when liquid is cheaper. Insurance doesn't care if some folks are scared of needles. Other than innovative delivery, it does not seem to have any medical benefit over traditional insulin. In fact, the long range effect of the powder in the lungs is an open question that has many folks worried.

BTW, it is honest-to-God real human insulin, not an analog. They spin the insulin into tiny drops that dry to between 3 and 5 microns. That is really, really, really, really, really small. Why human insulin, when that product has otherwise nearly disappeared from the market? I asked. The answer: they started working on this before analog insulin came along. Wow. Lots of time. Lots of dollars. Did they back the right horse? I suspect insurance will make or break this product.

That said, I love having another arrow in my quiver. My local Pfizer rep is coming by the clinic later this week. Once the insulin is available I'd like to offer it as an option to my patients who can either afford it or can qualify for assistance. Me? I'm willing to take a huff (or three), pop a couple of cherry slices and see what happens. After all, I still have the Girl to watch out after me. It will be interesting to compare the curve of inhaled insulin to that of pumped....

To my surprise, as things kick off, the clinical presenter is a friend of mine. She's the CDE who "fired" me, saying every time I visited her she learned something from me; instead of the other way around. As she starts talking the salads arrive. Looks good, but I leave mine untouched, as I'm taking notes. No one else seems to share my priorities. Next comes gumbo. We're at a Big Easy themed seafood place, which, I'm told, is based out of Chicago. Go figure. Big Easy seafood from Chicago in Albuquerque. Makes some sort of cosmic-global-economy sense, I suppose. I let the soup sit as well. I like free food as much as the next diabetic, but I'm an information junkie. This is interesting stuff. The wait-staff begins to collect the salad and soup bowls. I set my pen down long enough to grab a fork to threaten the girl's hand. Take the soup bowl, but don't touch my salad. Then the entree comes. 16 ounce rib eye. Oh my God. So tender you could cut it with a fork. I abandon my note taking and rely on my memory. I'm not letting this puppy get cold. I could also have chosen from crawfish, mahi-mahi, or chicken breast. This is followed up with key-lime pie. There was a good crowd, it must have cost a fortune. Earlier there were three kinds of appetizers. Turns out they also held sessions for Docs, and later will be holding one for my crowd. I wonder to myself if the menu is the same for all three groups, or is there stratification? Did the Docs get champagne? Will the Educators only get chicken and crawfish?
Most of the attendees leave as soon as their stomachs are full and the presentation is over.

Some even before the pie! Not me. That's why God created insulin pumps, right?

I close out the party, with just me, the CDE and the two guys from Pfizer.

As the CDE and I are chatting the rep says, "I take it you two know each other?" Yes, I tell the rep, in fact she fired me once. The rep now looks pained and doesn't know how to proceed. We both laugh. We talk about the good and bad points we can see with this new therapy. Then the conversation drifts to the new oral meds, Byetta, and continuous glucose monitoring. I have my Girl with me. My CDE friend has been wearing a Dex Com. We compare notes. We talk about the politics of insurance, the spread of diabetes. The UN resolution. And then it is 10 o’clock at night. She needs to get home to her kids. I’ve got a two hour drive home to Debbie and Rio. I try one last time on the way out to score an inhaler. No luck. The only way would be to conk the guy on the head with a coffee cup and steal the whole batch. I think about it for a second or two and it isn’t worth it. Oh well. Soon.

A stop at Starbucks for a iced latte. Some caffeine to get me home, but not enough to keep me up until dawn; and then it is off into the night, lightning dancing across the horizon.

A fun night. The smell of distant rain on the desert air. New info. Some hands on with the latest thing. Chatting with peers. Free steak. It doesn’t get much better than this.

And, no. This is not the new toy. But that is a story for another day....

Friday, July 07, 2006

Roll Call

OK OK OK OK OK OK OK. Stop pestering. I'll start posting again.....but not every day! Let's start with a roll call. Check in via comments and let me know you are still out there and are ready to read!

I've got Guardian updates, an exciting new job, and a new diabetes toy to report on (and it's not what you think it is.....).