Pumping 102

I’ve become addicted to MedT’s Quick-serter device for putting in infusion sets. It’s kind of like buying a car with power windows. Well, sure you could go back to rolling up your windows by hand; just like we could go back to hunting and gathering if economy and society completely collapsed. Yeah, right.

For those of you new to pumps the infusion set is another disposable. It is how the insulin gets from the pump to your body. The set consists of a coupling that hooks on to the reservoir, a thin plastic hose of varying lengths, and an IV-type needle and cannula on the other end. Don’t panic!

The needle is only a guide. You put it in yourself only briefly and then pull it out. It really doesn’t hurt most people most times. Fingersticks are worse. The business end of the set has a very thin cannula, think of it as a garden hose for Tinkerbelle (currently the love of Rio’s life). It is a tinny, super thin hose. They come in 9mm length for most of us and 6mm for children and the super skinny or super athletic who have no body fat whatsoever. I’m on the lean side, and I’ve still got plenty of subQ body fat for the 9 mil.

In a nut shell if you pump you stick a needle into your stomach once every three days. If you stick to shots you do it four to six times per day. If you’re diabetic, your world is full of sharp objects. Period.

Also on the business end of the set are varying types of tape to hold the set firmly onto your body. More on that in a bit.

Now with my CoZmo pump, I used Comfort sets. I had to pinch up a little bit of skin and slowly slide the needle in by hand. Smooth out the sticky tape to hold it to my stomach, then gently pull the needle back out, just leaving the cannula behind. It really isn’t a big deal after the first time. We won’t talk about the first time.

To use the Quick-serter, on the other hand, you just slip the infusion set into the springy-snappy-inserter-thingy. Pull back on the top to cock it. Hold it against your skin and….Wait! Stop! You forgot to take off the needle guard! That big upside-down funnel made of blue (of course) plastic. MedT must have gotten a really good deal on blue plastic dye back in 1968. They still have another 24 years of inventory, so get use to the blue…

I have no idea what would happen if you tired to Quick-serter that big upside-down funnel into your body, but I think it would be bad. So take the cover sheet off of the sticky tape, take off the funnel-shaped needle guard, then hold the Quick-serter against your skin, thumb and forefinger on the buttons on each side, take breath for good measure, squeeze the buttons, and….

And that’s it. You’re done. So anti-climatic. The needle is in, you don’t feel a thing. You pull the needle out, snap the needle guard closed (another cool MedT innovation) and you are finished.

Oops, hell. Forgot the IV Prep. Well, doubt it will be a problem, this tape is like super glue! IV Prep is a sticky liquid that both cleans the skin and helps the tape to stick better. It comes in little toweletts that remind me of the ones you used to get with Kentucky Fried Chicken orders. Only they don’t have that wonderful lemon smell.

I’ve used MedT sets both with and without IV Prep and they work fine both ways. The glue is very strong, but it doesn’t bother my skin (knock on wood to ward off evil). I also don’t bother with a “safety loop” either. Some pumpers, especially older ones, create a loop of tubing against their skin and hold it down with various types of tape. Theory is, it gives you a bit of extra cord if your tubing gets caught on something, which it will. Door knobs and stove dials just love infusion tubing.

I just tuck a loop into my underwear band. Never lost a set in my life and I get tangled up as often as the next guy.

One other cool thing about this set is that, being straight in rather than angled, the set is circular. You can insert it just about anywhere and angle the hose in any direction you want. I like that.

The connect/disconnect/reconnect is pretty slick too. Pinch the hub, rotate 1/8 turn, take it off. You are free from your tether. Also free from your life support system, so don’t dilly-dally too much. Still, I like to disconnect for my AM shower; partly for freedom and partly ‘cause ParaPump, mike most monkeys, really doesn’t like water much. I hear that other pumpers like to disconnect for intimate moments. I can’t speak to that personally ‘cause I’ve been married for 18 years and we have a wild five year old who never sleeps. No intimacy in my life.

Next time: prime and rewind

Pumping 101

Time for a new set. I’ve gotten disorganized and ParaPump has been warning me that I’m running on empty. A quick check of the pump status screen shows me I’ve got juice for six hours of basal. It is after 10pm…I’ll run dry at four in the morning. I think I’ll change my infusion set tonight instead of in the morning. It gives my bride, who’s usually snoozing during site changes, an opportunity to check out the new gear. I spread out the tools of the trade on the kitchen table.

Reservoir. Check.

NovoLog vial. Check. Looks like there is just enough left for one more fill up of my 522’s baby 176 unit reservoir.

Quick-serter. Check.

IV3000 and new lancet needle. Check and check.

Reservoirs come individually wrapped in long perforated sheets, like an ammo belts for those big machine guns. You can tear them off one at a time. I think ten or so come in a box. For those of you new to pumping I’ve probably done you a disservice in not laying out more clearly how the whole system works. The reservoir is the clear plastic syringe-like cartridge that holds the pump’s insulin supply. You fill it to suit your needs for a three day period. It is one of the disposables. The pump will drip little bits of the fast acting NovoLog or HumaLog into your body 24-7, 365. This covers your “basal” needs.

Basal is the insulin that keeps you alive between meals, at night, and when you are lost on a deserted island with nothing to eat. When you eat you need either a lot more insulin, a whole lot more insulin, or tons more insulin—depending on how much you are eating and what you are eating. This meal time insulin is called Bolus insulin. In a pump, the two types of insulin are the same juice, the only difference is in how it is delivered.

You figure out your basals needs by time-consuming trail and error. Some people can get by with one “rate” all day and all night. Most people need different rates for different times of the day. We call these different rates the “steps” of a “basal pattern.” Again, one size doesn’t fit all. Most folks have four to six steps. I happen to have 18 steps throughout the 24-hour day. Once your pattern is established you can program it and forget about it. The pump will handle this part on its own. Of course you can increase it or decrease it at will using a feature called a Temporary Rate. For instance, on days that I work at the clinic I get so jazzed by the excitement of the work that my sugars skyrocket. I’ve found that using 150% of my normal basal rate for ten hours usually does the trick. Other, more athletic folks will use lower rates while they are working out.

Bolus insulin takes some work to figure out too. In a nut shell, you need to know or guess how many carbs are in the food you are going to eat. Carbs are various types of sugars, both natural and un-natural that are in most foods. Carbs impact blood sugar very quickly, which is why we worry about them. Type 1 Diabetics need to “cover” the carbs we eat with insulin. Every time you put something in your mouth you’d better be pushing buttons on your pump. It sounds like a lot of work, and it is. But funerals are a lot of work too. A quick and important point. The pump is NOT an artificial pancreas. Nor does it serve as a replacement for your brain. Even with CGM, the pump part of the pump doesn’t know what your blood sugar is. Just because your sugar is displayed on the screen doesn’t mean your pump is any smarter than you are. You must tell your pump what you want it to do. Even with our fancy CGM and B-wiz, the pump is just a time saving tool, not a miracle. You must think about what you are doing. You must tell the pump what to do. They are working on closed-loop pumps, but it’ll be quite a few years until your Doc can write you a script for one.

Anything you are eating out of a box will have the carbs printed on the side or back. Some things are “free” of carbs. Modest amounts of protein, for instance. So you can eat anything that runs, flies, swims, crawls, or slithers without taking insulin. Cheese is safe too, as are most veggies in small amounts (beware corn and carrots!). For real food there are a ton of resource books you can use to look things up, and in time you can get pretty good at estimating by looking. In more time you’ll get lazy and be wrong more than you are right. One of my crew (I’ve trained three of our best “control enthusiast” patients to become Diabetes Peer Educators at the Clinic) has a great set of about a thousand food flash cards. He has a blast doing carb drills with other diabetic patients.

Usually basal is half the total insulin you use in a day, and the other half is bolus. Excepting days that you find yourself at the all-you-can-eat buffet and China Star, you generally use about the same amount each day. You fill your reservoir with that much plus a little extra, just for in case. Or maybe you don’t. Depends how well your insurance covers insulin.

MedT has built a better mouse trap with their Paradigm reservoir. It’s topped with a (you guessed it) blue plastic “transfer guard.” The guard is the best thing since saran wrap. It is a little bracket that securely holds the reservoir in alignment with the vial of insulin. It reminds me of the little docking collar they used for the Apollo/Soyuz rendezvous back in ’71. Ya just snap the insulin vial onto the top of the collar, pressurize the vial by pushing down the reservoir’s plunger, tip it vial-side-up and draw the insulin into the reservoir. Slick.

The transfer guard even places the needle just inside the vial so you can suck it dry. OK, I gotta admit it. I’m really liking the MedT Paradigm infusion set system. The whole kit and caboodle, and I’ve never had fewer bubble head aches! I like the little baby reservoir that actually is the size I need.

Next Time: more on pumping and the MedT ParaPump system parts and pieces.

Yo Hablo Medtronic

No wonder none of us can talk to each other! Here’s Printcrafter’s translation guide for CoZmo users wanting to learn MedSpeak.

IOB (insulin on board) = active insulin

Combo Bolus = Dual Wave

Extended Bolus = Square Wave

Load = rewind

Fill canaula = Fixed prime

Insulin to carb ratio = Carb Ratio

This really boggles the mind. Am I just use to the CoZmo terms, or are they better? Why, when MedT was first to market, do they have all the crappy syntax?

Good news, bad news

I was drifting down when I lost the signal. The last SG reading was 102. About fifteen minutes later I got the lost sensor alarm. Damn. I try to reacquire. No go. I pull the transmitter off, plug it back in. No Roswell-Alien green light. Double damn. I’m at the clinic, no spare sensors here. Hmmmm… need to think about that. Should I keep a spare in my fridge here in my office, snuggled up with the Novolog, Levemir, Lantus, Mix, and Humalog samples?

Back to frequent fingersticks for the rest of the day.

My musing is interrupted by unexpected walk-in patient. Rough looking young fellow sent by his probation officer to have his sugar checked. Huh? Turns out he failed a urine test for alcohol. The officer thinks if his sugar is high it might effect the test. That’s a new one on me, but could be true. Turns out the punk is the son of one of my patients. Actually, he only looks like a punk. He’s actually a nice kid and we have a pleasant chat. Well, I guess he can’t be too nice if he’s on probation. Oh well, he’s friendly and has a good sense of humor. His visit presents my first opportunity to log an electronic encounter.

All week long this week we’ve been moving over to electronic medical records. Huge expense. Huge headache. Long term it will be wonderful. So it’s kind of like getting a root canal. Painful now, but in the long run you’re glad you did. Everyone but me got sexy new tablet computers (still pouting).

I’m still working on my desktop. Actually, that’s not true. I got my bosses’ desktop because mine was sooooooo old it couldn’t handle the new software. Our IT guy actually apologized to me. “I didn’t know we had any antique computers still at the clinic,” he told me. There are advantages and disadvantages to having an office in the Annex. Lots of privacy, but sometimes the powers that be forget we exist. Overall, a worthwhile trade in my book.

What do you want me to do with the old computer, IT Guy? He suggests I donate it to the Smithsonian to be displayed next to the Wright Flyer. In all fairness, it wasn’t that bad. My first six months at the clinic I had a big honking CRT monitor that literally took up half my desk. I was so happy to get rid of that nasty thing and get a thin, lovely, bright flat panel that the speed of the old computer never bothered me much. I mainly used it for inter-office email and checking EBay and blogs, on my lunch break, of course.

I got the hang of the new software pretty quickly. It is wonderful to be able to check my own schedule. Due to the number of licenses on our old schedule program, I never had access. I always roll my chair back so I can see out my door and holler down the hall, “Jane, do I have a 3 o’clock on Wednesday? What? I do? Uhhhh….what about 4 o’clock?” Now, not only can I check my schedule, but will ultimately I’ll be able to have all patient facts at my fingertips. Once everyone is in the system, that is. Depends who you ask how long that will take, six weeks, two years, sometime in 2030, or never.

Still, what power, in the best sense of the word. A patient calls with a question on their meds, I don’t need to run for a chart, I can call it up on my computer. All patient visits will be entered directly into the system too. No more paper charting at peril of your job, according to our director. That I worry about. Not that I can’t do it, but what it might do to the Zen of a patient visit. Can you image trying to share your hopes and fears with a guy typing on a computer? Well, we’ll see how that works out, but I can’t help but think I would have been better with a tablet computer in my lap. Well that’s what I thought until I actually got to use one of the tablet computers.

The kid whose probation officer sent him in is over in the main clinic waiting for me, so I scoot over to the nurse’s station to snag a tablet computer for the first time. I have no trouble talking a colleague out of her computer. All of the nurses are pretty frustrated and saying things like “I didn’t get into nursing to stare at computers” and “If I never have to look at another computer screen again in my life, it will be too soon.”

I delightedly start to demonstrate my prowness with the software on the snazzy new tablet and I get into trouble almost immediately. I get frustrated pretty quickly. The damn thing doesn’t recognize any of my letters. D-Screen becomes D-Scream. Well, in hindsight that’s pretty funny, but at the time it was stressing me out.

I finally push the thing away and grab a meter and a sheet of paper. I don’t want this poor kid to have to wait forever to get his sugar checked. He was 126 one hour after eating a burrito and drinking two gatoraides. Not a member of the tribe yet, but we had a talk.

After he heads out I go back to the tablet, determined to get this brief encounter into the system. Not a live entry, but postlive. Better than nothing.

Almost at once things go south on me again. When I try to backspace weird things happen. The computer then shuts down and my hands start to shake. I feel my blood pressure going up and my brain begins to fog. My mental processes are mired in molasses. I’m getting pissed off when a distant memory floats into my head.

……could it be?

……might it be?

……but I haven’t for years…..

I don’t have a meter on me. I’ve gotten lazy, why lug a meter around when you’ve got a ParaPump giving you BG data every five minutes? Luckily, working at a health center, there is never a meter too far away.

Grab glucometer. Snap. Zipppp! Wait for it, wait for it, wait for it….66.

Crap. Wouldn’t you know it. The first time ParaPump takes a coffee break I crash. But I felt it. Wow. I felt a hypo again.

What a great feeling to have such an awful feeling.

Of course, with my head resting on the tablet computer and drool coming out of the corner of my mouth, I look just like the rest of the mentally overtaxed medical team. It never occurs to anyone that I’m hypo…. Lucky thing I keep some very stale Cherry Slices in a drawer at the nurse’s station. Zip lock bag, labeled “Paws Off; Wil’s Hypo Candy.”

But I felt the hypo.

Next time: more on When Sensors Fail (take off on When Animals Attack).

Long Day

6 a.m. alarm goes off.

6:50 a.m. leave for work.

7:57 a.m. arrive at clinic.

8 a.m. to 6 p.m. assorted medical adventures, one sensor failure, one nasty hypo.

Drive home, pick up child, go post-rosary reception. Return home.

Now 10:18 p.m. Funeral in ten hours forty minutes.

Yikes!

I think I’ll sleep rather than post. See ya all tomorrow.

Diaburnout

Hi. My name is Wil, and I’m a diabetic.

Of course, I don’t ever need to stand up and say that. Everyone around here knows. But I do have a confession. The last few months I’ve been absolutely sick of being diabetic. I work in it. Volunteer in it. Teach it. Study it. Live it. And I’m tired of it.

It crept up on me a little at a time. I didn’t realize I was burned out at first. In retrospect, the first warning sign was the Watch.

Back in the fall Medic Alert was taking advanced orders for their new watch. Still being an energized, enthusiastic diabetic at the time, I placed an order for one. It came, months later in early February. I got the band adjusted, then never wore it. I stopped wearing my bracelet too. Not totally insane yet, I still wore my alert necklace… under my shirt.

I got lazy. Checked my blood sugar less often. By the time I lost my Guardian I had pretty much thrown in the towel. I just let the sugars run high, less worry than checking all-the-fucking-time. I still couldn’t feel the lows. I’d catch them by dumb luck. On one level I knew it was only a mater of time before dumb luck caused one of them to catch me. I got fatalistic.

Rather than springing out of bed full of ideas and eager to get to the clinic, I hit the snooze alarm three times then drug myself to work. I use to be the first one in, now I was barely there in time for my first appointment. When I met with patients I still got energized. I probed, questioned, inspired and motivated them. I was on top of the world; until they left my office. Then I fell back into my personal pit of dark despair.

I began to feel like a fraud. Everyone looked up to me. My patients were all getting healthier due to my teaching, but I was getting sicker due to my actions. It was like our roles were reversing. While their A1Cs collectively marched downwards on my watch, mine marched upwards—opposite paths on the same stairs.

Anybody remember the song about the junk-food junkie? It was about a health nut who lived a secret life eating less than optimum nutritional choices. He was afraid they’d find him “just stretched out on my bed with a handful of Pringles potato chips and a Ding Dong by my head.” (Amazing the crap you can find on-line with Google.)

I began to do less and less work outside the clinic. One-by-one I let my various volunteer D-gigs fall by the wayside. I was asked to bid on a D-ed contract with the county and I passed on it. I pared back my schedule and cooked up fewer and fewer schemes and outreach activities. I basically just kept to my schedule and left it at that.

Then three things happened. The first was my health. A new A1C of 8.4. My highest ever. Creatinine up too. The kidneys were unhappy. The second was The Group.

I hold group education and support sessions every month. I had put them on hold over the winter because we had a really rough winter and it seemed that asking chronic care patients to brave snow, ice, and dark for support group was just not good medicine.

At our spring re-launch we had a HUGE turnout. It was like Arab flea market meets first day of kindergarten. My head is still aching. Our Exec Director recently replaced out conference room’s shabby thread-bare carpet with saltio tile. Good idea in theory, but now the place is an echo chamber.

I digress. Anyway, for days after the first group of the year my patients were raving about how great it was, how much they learned, how less isolated they felt. So I was starting to feel like I’m doing some good…

Then I got the ParaPump. Don’t tell anyone, but at the time MedT called I was so depressed that I almost declined their offer. Oh crap, I just told the whole universe, didn’t I? Oh well. That’s me, the open book.

So now I have motivation from all sides: fear, peer support, new toys. I’m wearing my bracelet again. Tomorrow I’m going to brew some Starbucks, put on my medic alert watch, tweak the basal rate program on that ParaPump and get my diabetes back in the cage it belongs in.

Hi. My name is Wil, and I’m a born-again diabetic.

Fun with Dick and Jane…. and the remote

So we are meeting with a young couple whose wedding we are shooting in three weeks. They’ve already hired us, but this is the pre-wedding meeting to hammer out last minute details.

They have chosen a high carb restaurant for the meeting.

Normally, I don’t care whether or not people know I’m diabetic. In fact, I always take the view that I’m an ambassador from our tribe to the rest of the world.

However, a woman who is three weeks away from her wedding doesn’t want to learn anything about diabetes. Or any thing else, either. Whipping out my pump could give her visions of her photographer going into a coma as she says “I do.” THUMP. CRASH.

Perfect excuse to try out the Remote Control. The remote drives old fashioned basic boluses, which means you can only deliver pre-determined steps of insulin with each push of a button. You have to count your carbs and do the math in your head. I wish they had the option of letting you punch in the carbs with the remote and let the ParaPump do the math based on the time of day, but oh well. It is good practice to do things the hard way now and again. For my remote use I chose to program a “step” as a full unit of insulin, and then set the pump to vibrate. The remote has three buttons. ACT plus S and B.

We are in a booth at the delightfully noisy Blue Corn Café on Cerrillos and Rodeo in Santa Fe. Of course, I could have just taken a bolus in the parking lot before I went in, but this was so much more fun. Also doesn’t hurt to have the alarms on vibrate during client meetings… We are chatting and laughing and the young couple are sharing tales of the last minute wedding planning when the waiter brings us the chip sampler.

I lean back in the booth and casually slip my hand into my jacket pocket. My fingers find the remote, recognizing the bottom by the key ring. Like reading Braille, my fingers slide over the surface sightlessly seeking the three buttons. I find the large oblong ATC button by feel, press gently in, and hold it. The ParaPump shutters on my belt to let me know it’s paying attention. Next I slide my thumb up and to the right to the B-for-Bolus button.

I bolus first for the chips. One unit per ounce at my mid-day ratio of 1:15. Come on, fresh hot chips with salsa, queso, and guacamole? One….Bzzzzt. Two….Bzzzzt. Three….Bzzzzt. Three full units. I press ACT again and the ParaPump reads back It’s marching orders: ….Bzzzzt. ….Bzzzzt. ….Bzzzzt. One final stab of the ACT button and the insulin is set free.

HeHeHe. No one knows what I’m doing. Not even Debbie. Perverted rush. It’s like doing something naughty in public with all others unaware.

My quesadilla arrives. Under the table I fondle the remote again while I dust off my brain. Two tortillas, 18 carbs each…that’s 26 carbs… no, wait! That’s 36 carbs. Flash back to fourth grade when they tried to force me to memorize my times-tables. I missed a lot of recess…. One….Bzzzzt. Two….Bzzzzt. Three….Bzzzzt.

Did you guys save room for desert? asks our waiter. Debbie and I split a chocolate volcano (don’t ask). One….Bzzzzt. Two….Bzzzzt. Three….Bzzzzt. Four….Bzzzzt. Five….Bzzzzt. Six….Bzzzzt…..

Caveman Low

ParaPump is like the national weather service: it can’t stop the weather but it can give you time to batten down the hatches. I saw the hypo coming, a nice gentle downwards slash across the three hour BG screen. Looks way more terrifying on the 24 hour screen. Significantly more perpendicular. The alarm never actually went off before the storm hit.

I’ve go my low alarm set at 75, which from my own experience is actually a bit too low. For those of you not in the loop yet, the ParaPump CGM readings “lag” behind fingerstick glucose. There are a couple of reasons for this, and it is not a fault or design flaw. They are the simple results of biology and mechanics.

First: sugar in interstitial fluid, which is the “water” between your cells, tends to lag behind the blood flow a little bit; not unlike how a forearm test will lag behind a fingerstick test. Did I remember to tell all of you that the MedT sensors measure interstitial fluid? Second: Continuous Monitoring isn’t continuous at all. In reality it is one measurement every five minutes. Anybody know how fast a hypo moves? That’s right, just slightly faster than a brick dropped from a supersonic airplane. You’re BG can drop quite a bit in four minutes fifty-nine seconds.

So back to threshold settings. Ideally, you should set your “low alarm” quite a bit higher than where you would actually intervene. After all, a dainty beep that you probably won’t hear anyway doesn’t require you to actually do anything. This is not a tornado warning that requires immediate action. A low alarm on a CGM is just a head’s up. A clearing of the throat. A nice way of saying: pay attention!

Best advice, set your alarm at least 10 points higher than your intervention threshold. Higher still would be even better. Some folks even use 95. I used 85 a lot with good results until recently. The problem got to be that my sugars in the wee hours of the night would gently drift down into the mid-eighties. It was basal driven, the bolus insulin on board had long since run its course. It was safe, solid mid-eighties. With alarms every hour. I was a zombie. So I backed my alarms off. Probably too much. By the way, you can set different thresholds for different times of day on ParaPump. In theory, during the day you could use much higher thresholds for tighter control. An alert that requires no real action is less of an annoyance during the day than at night. Of course, you could argue that at night is when you are more at risk and so…. Well, anyway…

So watching the steady drop, I told myself I needed to go do a finger stick. I knew the “real” BG was ahead of the curve. In other words, dropping at a steady clip it was almost a guarantee that the fingerstick would be lower than the readout on the ParaPump.

I headed for my night stand. Then the peanut incident happened. Rio decided to open a container of chopped peanuts on the bathroom countertop. Yeah, the one with the rough tile surface and deep grout lines. Then, just for good measure, he peed on the floor and decided that the safest course of action was to not mention it to anyone.

So between mopping and sweeping and putting away toys I neglected to test my blood. What was I doing? Oh, yes, I was going to do a fingerstick. Let’s see where ParaPump calls the game. ESC button once. Hmmmmmm….down to 76. The alarm will go off at the next sampling. Still trending down on the graph with no sign of a plateau. Where’s the nearest Accu-Check? Nightstand. Pop! flip canister open with thumb. Remove KING SIZED test strip. Snap! lance finger. No blood. Damn. Snap! lance finger again. Still no blood. Switch finger, set dial for deeper punch. Snap! Ouch! OK, now we got us some blood. Ummmmm…. lots of blood. Ziiiip! And the winner is:

58. Oh crap!

Well, that got quite a bit ahead of me. No Cherry Slices left in the house, a sad story I’ll post about some other day, all I have so far is the title: Ode to Cherry Slices. I pop a glucose tab and wait.

One minute. Two minutes. Three minutes. Four minutes. Five minutes. Six minutes. Seven minutes. Eight minutes. Nine minutes. Ten minutes. Eleven minutes. Twelve minutes. Thirteen minutes. Fourteen minutes. Fifteen minutes. Time to retest.

Pop! Snap! Ziiip! 59. You gotta be fucking kidding me. Of course, I don’t feel a thing, other than fear. No shakes. No sweats. No dropping elevator.

Now a little known medical fact is that once you are below 100 BG your IQ drops point-for-point with your blood sugar. At this moment in time my IQ is a caveman low of 59. I’m now running on pure instinct. The brain has left the building. And what are cavemen most famous for (other than fabulous cave art)? That’s right. Killing wooly mammoths with stone-pointed wooden spears and eating them. Eating the mammoths that is, not the spears.

I closest thing to a mammoth in our house is the pantry. Through my fogged brain I recall that somewhere in that cavernous cabinet is some trail mix with dried pineapple. My salvation! Quick acting sugar in the pineapple, slower carbs to re-fill the liver in all the nuts and stuff. I grab my spear and head for the kitchen.

I never did find the trail mix. I did, however, find the caramel covered popcorn. And the gummy worms. And the jelly candies. And the cookies. And…why the hell do we have all of this crap in the house? Ooooooo, Fruity Pebbles! Need milk. Go to fridge. Strawberry milk? Why not? The Pebbles are Fruity, why shouldn’t the milk be Strawberry?

It is all a fog. I don’t remember what or how much I ate. It was like an out-of-body experience. I knew I didn’t need to eat that much. But I couldn’t stop. The safety’s were off.

It was a caveman low.

I went to bed when I was too full to eat another bite. As my IQ returned during the excursion I threw four units on the fire.

And then I slept through the high alarm.

Spider Webs

Once again, way up on my isolated hill in New Mexico, I am connected to the world.

CareLink only exists online. Not sure why. They are probably conducting some sort of secret research on our BG data. Who cares? If you can’t trust MedT, who can you trust? Think about it, they already know you are diabetic.

So now that I have a cable, I go to the CareLink site. What did I use for the fen’ username and password when I signed up for the cable the other day? Was it D-Stud? SuperBetic? Oh yeah, I used ************

You really didn’t think I’d tell you my password did you? Like all other Americans I use the same one for email, bank accounts, ATM card, suit case combo….

Turns out I need to download a Java plug-in, whatever that is. I’m told it will take a few minutes with high-speed and 45 minutes for dial up. God help all who only have dial up. We pray for your sanity tonight.

I wonder what this new software will be like? It can’t be worse than UnSolutions that Guardian used. No, seriously, it can’t be worse. That was the sorriest excuse for software I’ve even seen…. My Sinclair computer in 1980 had better software….

Well that took a while, but Java is up. I got a momentary heart attack when they told me at CareLink that I needed a serial connection….. Nooooooooooooooooooo! They sent me a USB! The calmer side of my head prevailed and I soldiered on. Worked out fine, much like the PAL download, but slower. More data or my crappy internet connection. Or both.

You can now go to reports, or log book. I went to reports. Oooooooo, there are a bunch of them! Gotta go explore!

Well, there are a dozen different reports. Here are the ones I think are the coolest and most useful:

Sensor Daily Overlay. This gives you a midnight to midnight graph of blood sugar. You can pile seven days of traces onto the graph. Each one is a different color, and in addition, the software adds a dashed line for the average. Makes it really easy to look for trends. It also includes a statistical analysis of excursions, both high and low. The breakdown shows you not only the number of each, but the duration. Very cool. They also have a similar graphical report broken into meal times you can specify. You can also specify the pre- and post-meal study period. This report is called Sensor Overlay by Meal.

Daily Summary. I like this one, but it is not quite as nice as the similar snapshot in the Co-Pilot Software the other guys make. This is more like an early Windows knock-off of the Mac operating system. Still, you’ll use it a lot. There are three strips. Along the top is your sensor trace for the day, that bizarre Amazon-river-from-space view of what your blood sugar was doing on a given day. Overlaid on that are fingersticks and alarms. The middle strip is the Insulin Delivery pane. It shows the pair of Mayan pyramids that represent the steps of my basal rate. Vertical bars show bolus insulin, the taller the bigger. The bottom pane shows your carbs. Just small blue (of course) dots. There is a carb scale of 0 to 150 along the side. They “graph” your carbs. This is the place where Co-Pilot is better, they use ever larger circles to mark the size of the carb load. A huge meal looks like a nuclear explosion on the Co-Pilot chart. Very easy to interpret. That said, once you train your eye for the CareLink graphs you can quickly take in the interplay between carbs on the bottom, insulin in the middle, and glucose on the top. Some useful stats litter the bottom of the page. If you printed these out every week and sat down with your food log….

There are also Modal Day by hour and time period reports, and a Quick View Summary that shows you trends.

I’ve only just begun to explore these reports, but they seem a huge improvement over my last experience with MedT software. There is a lot of data, and it is presented in a way that is useful, helpful, and possibly powerful.

Now I want to raise the bar (further proof that it is impossible to keep us D-folk happy). This software is passive. All it does is display data. What about a software that actually does something? What about a software that helps us analyze the reams and reams of data that continuous sensors produce? Why couldn’t the software see that I took a correction bolus at 3am that didn’t work and suggest a new correction ratio based on the data that might work better? Why couldn’t it study our basal patterns and suggest fine tuning? Why couldn’t it tell us which carb factors seem to work and which don’t?

Why couldn’t it?

Reply to comments

First off thanks for the blizzard of email condolences on the passing of Deb’s Grandmother. I had posted late at night and my blurry eyes missed the fact that I had mistyped her age: she was 86, not 69. I’ve amended the post, but a lot of you had already read it by the time my brain was working again the next day.

I haven’t had the chance to respond to questions and observations left in the comments sections, so I thought tonight I’d do that post-by-post. I’m just attacking questions or things I felt compelled to comment on, so I won’t list all of you name-by-name. Don’t take offense, I love the positive feedback, it’s great for my ego!

Calvary. Anonymous: yeah, even with the things that drive me crazy, the ParaPump system is an answered prayer. I’m often harsh ‘cause I get bugged when something is only 75% wonderful when there was no reason for it to not be 100% wonderful. I’m really pretty happy with the system, and I get more so everyday. Val: I’m probably one of those people who washed the lottery ticket that was never claimed… Scott: soooooo much to talk about, I’m really gonna try hard to post every day.

Box. Janna: I haven’t messed with the CareLink logbook yet. What I really like is being able to see the traces of the BG from the sensor. No real value to you if you don’t use the CGM (yet!). Tom: thanks for de-lurking, welcome! Bernard: software does seem to be a low priority for diabetes companies. Julia: OK to be jealous. Megan: I actually went through three CozMonitors in two years. They just mysteriously crap out. Each time Smith’s sent me a new one for free, but never commented on what went wrong.

Boxes. Janna: my home town pharmacy in Podunk New Mexico had the BD strips in stock, bummer you have such trouble in the Big Apple. For me, the bigger problem has turned out to be my new insurance from the clinic. The BD test strips are upper tier. They charged me $55 bucks for 150 (which really isn’t enough for a month anyway). I called the customer service folks and was told Accu-Chek was preferred and that I could have any number of strips my Doc could justify for $10 bucks a month. Good deal if true. Stay tuned. Meantime, I’ve been using the BD Link some, and also playing with a Accu-Chek Aviva to get use to it. It is, like all these damn things, both good and bad. Overall, not too bad. I’ll devote a post to the Aviva later. Oh, and the remote—fun, fun, fun. A post all about my first experience with it is coming up in a few days. So, sorry my well-endowed friend, I’m keeping it for my selfish self! Allison: I always love to hear your four-cents worth. A lot of folks have been emailing me about the BD meter. About 70% hate it. Many reports of inaccurate readings at low BGs. I haven’t had a real spectacular hypo yet to try it out on. Only a matter of time, I’m sure…. Julia: new transmitter more wonderful than words can describe. That said, I’ll throw some more words at it soon.

Homework. Anonymous, well as I work in photography about half the week, you’d think I could manage some images…but fitting that in has proven problematic. Don’t look for any real soon, but maybe down the road… Aaron: the Pal software is a great way to program the pump, but for what ever reason MedT does not include the cable necessary to make it work with the basic pump package. You’ve got to go on-line to CareLink site and request it. They did ship it out promptly, but by then I had already programmed the pump. It’ll be great for updates and fine tuning though! Jana: I agree that the B-wiz and the idea of a target range is an odd couple. I didn’t bother with a range and just set both high and low at 115 from 7pm to 7am and at 100 for the daylight hours. Wanted slightly thicker ice under my feet for nighttime corrections. Penny: trust me, the new transmitter will not be too large for your little D one. Scott: as soon as I read your note I ran and got Hirsch’s book from my nightstand. It has been sitting there along with Amy’s book waiting for a chance to read. I haven’t cracked either open yet. Also on the pile unopened are Thom Hartmann’s Screwed, Dr. Bernstein’s updated tome, a the latest Tony Hillerman novel and a half-read copy of Friedman’s The world is flat version 2.0. I went to page 150 of Hirsch’s book, and sure enough you are right, he quotes my most popular post…minus my name. Oh well.

Magic. Megan: keep in touch on your BD, let us know if you have better luck than in the past. I’ve received a lot of scary emails about the meter since I posted my happy thoughts about it. Lili: that is true, you still need the BD for your computer to talk to your pump and visa-versa. MileMasterSarah: we all live and die by our insurance companies. Literally. Randee: lack of a back light is a huge problem with the BD, and also with the Accu-Chek my insurance will pay for. I hate having to fumble for both a flashlight and a meter and strips and a lancer in the dark. Mini/Flash also has a cool strip-port light that sends a beam of light down the strip so you can test in the dark. Also works while driving at night. Not entirely safe, but very useful….George: I’m hearing a lot of insurance companies love the One Touch. Good meter (all three of the current models) and great strips in my experience. Allison: in my book, if a meter doesn’t work low, it doesn’t work.

Pumping? Tom, if you blog the concept of “I live, therefore I pump” please let me know, I’ll want to read it. Sad truth is, although I love all of you I’m sooooo short of time I only read three fellow bloggers (and even then, not every day). I read Amy at DiabetesMine, she’s the New York Times of Diabetes. I read Kerri at SixUntilMe because like everyone else I can’t help but love her. That said, if she has one more hypo without some sugar on her body I’m sending her a carton of glucose tabs… And I read Scott at Scott’sDiabetesJournal because we’re cyber buddies and I love the way he writes and thinks.

Mistress. Jana: thanks for the tip on peering through the murky crystal ball of the ParaPump menus to figure out insulin on board. And you’re right, I had figured it out. You can actually enter any BG and any carb amount to make this work. If you leave the BG blank the active insulin will also appear blank. I use 115 and 1 carb for the minimum number of button clicks. Every time I have to do it I get pissed off on two levels. First that I don’t have an active insulin screen to look at; and second off that the stupid ParaPump always goes back to a blank screen rather that showing me something useful. Anonymous: alarms that are too quiet are the real Achilles heel of this system. Of course, right now, no one else has a pump with a CGM built in, so ParaPump with it’s assorted quirks and weaknesses is still the best game in town. It’ll get real interesting when other pump companies start making CGM pumps. A feature like an alarm that really doesn’t work will cost MedT boat loads of customers if one of the other guys has a system with a loud alarm. I can’t fathom the decision that lead to an alarm without a volume control. The original Guardian had a wonderfully loud alarm, and personality too. Are you using the new MiniLink transmitter or the larger older one? The MiniLink will lose signal sometimes, but seems to keep a more robust connection to the ParaPump. Aaron: glad your wife is there, but what about all the diabetics who are single? Or whose wives sleep with their children instead? The alarm should be loud enough to wake the dead so that we don’t join them.

Pie eating. Glad to keep all you CoZmo pumpers happy…. But I do have to admit, once you get used to the system it isn’t as bad as it seemed at first. And when the pie eating contest is over I’ll be first to know I’m having an excursion when my high BG alarm goes off. Of course, I won’t hear it….

Dark Clouds. Arron: too big a hassle to carry different types of meters for different jobs. I went all-manual and switched to Accu-Chek due to insurance coverage of strips. As I have a limitless supply of BG meters of all types I’m test driving Gary Scheiner’s approach as revealed in his wonderful book Think Like a Pancreas. He keeps meters all over the place. I now use six (yeah, I know, sounds like overkill, but my life is complicated). I’ve got one in my car. One in my wife’s car. One on my night stand. One at the lab. One in my digital camera bag (weddings and events). One in my film camera bag (art and personal projects). Oh. Yeah. One in my “Go Bag” that I carry all the time and has my assorted backup and emergency supplies (and both a small digital camera and a small film camera), and there is One on my desk at the clinic which I also use for screenings. OK, so I guess I have eight, not six. Damn. I feel like a diabetic version of Imelda Marcos with all her shoes… By the way, thanks for the tip on how to turn off the send feature on the meter. I had shut it down at the pump end, but when I do still use the BD from time-to-time the poor thing blinks for hours searching for the pump. Very sad. Like a lost kitten. Now it acts like any other meter. Like anything else that pisses me off at first, it turns out not to be that big a deal. We humans adapt quickly. Entering BG manually is a minor pain, but in the greater scheme of things…No wait. Screw that. MedT should not have done this to us. I’m not cutting them any slack on this. A minor change in the programming could have made all of the parts of the system work in harmony like a well oiled machine. That didn’t happen. I’m going to keep harping of this until it is fixed!

Pal. Randee and Aaron: always lots of good reasons for a backup program. Anyone out there ever NOT have a computer failure? Lili: I have not pushed, pulled, prodded, bent, folded, spindled, or mutilated the connector that plugs into the test strip port. That said, it did look to me like the kind of thing that could get broken pretty easily if it were thrown in a draw or fell into the hands of a five-year-old boy. As soon as I down loaded the pump, I put it back into its plastic hood. Good safety tip for everyone.


Tomorrow: back to our regularly scheduled program

A change of plans

It was not the day we had planned. We were all up early and on the road. We checked the mail and dropped Rio off at his Nanna’s house for the day. Our laptop was charged and ready and Deb and I were off to Midas. Yeah. New struts for the CRV. All day job we were warned. Our plan was to camp in the lobby and work on designing some sample albums for the studio using nifty new software from the album company. Once the car was done the plan was to visit Rio’s “Big Grandma” at St. Vincent hospital, then head back home.

Rio’s Big Grandma isn’t actually very big at all. She gets her title from rank, not size. She’s the matriarch of Deb’s family and is actually Rio’s great-grandmother. Deb had called her great-grandmother “Big Grandma” too. But the time Rio came along the original Big Grandma had passed on so the next Grandma in line took the title.

As we pulled out of the driveway after dropping Rio off we got the call that changed the day. It was a nurse in ICU. Things had taken a turn for the worse. The Doctors wanted to meet with Debbie.

We dropped the CRV off at Midas, who were kind enough to give us the use of a battered Nissan for the day. We went straight to the hospital.

Big Grandma has been in a rapid decline for the last six months, from semi-independent and fully functional to frequent flyer discount at the hospital. The medical team’s prognosis: it would take heroic action including feeding tubes, etc. to keep her with the living. It was up to Deb. Grandma was DNR, which means Do Not Resuscitate. She had chosen this herself a number of years ago. That means the Docs can’t restart the heart or lungs if they fail. Below that it is a slippery slope. Where does the feeding tube fit in? Are massively aggressive antibiotics on the fence or over the line? She had been on “pressors” for days. This class of IV drugs brings very low blood pressures up to normal levels. Usually they are more in the spirit of one shot use. Not intended as a maintenance drug. When they tried to back off, her blood pressure would crash. Had the line already been crossed?

My wife, the last of her line and Grandma’s only living blood relative was left with the agonizing decision. Intervene “heroically.” Stay the course of aggressive treatment. Or back off and late nature take its course. She was faced with trying to balance her own desires, her sense of what’s right, her knowledge of what her grandmother had wanted in the past and what her grandma was saying now in her diminished capacity.

With great difficultly and great courage she made what I think is the best, most humane, and only right choice to make in this situation. Let her die with dignity. Go no further. In fact, get some of this crap off of her, keep her comfortable. Let nature take its course.

Once the decision was made things proceeded in a uniquely New Mexico way: nothing happened until the priest arrived. Once the Father was in the ICU the man of God and the women of Medicine both began their assigned tasks. The priest was a Dominican, I think, with a long chocolate brown hooded robe. From a hidden pocket in his over-sized sleeve he took out the Caesar-purple ribbon emblazoned with crosses. He kissed it and placed it over his shoulders. The dialysis technicians clamped the holes pulling deep red blood from Grandma’s arteries into the filters. One of the women was about 8 months pregnant. I was struck with the circle of life. One life was drawing to a close, another was about to begin. The Priest got out his well-worn pocket prayer book and absolved Grandma of her sins while the “pressor” drip was stopped and the IV tubes were removed. As the priest anointed her with oil the nasal oxygen cannaula was removed.

And then it was done, both the church and the hospital had prepared her for her journey to the next world.

In only a few hours her blood pressure dropped to 39 over 11. Her breathing began to slow. Her cataract fogged eyes were closed and she was resting peacefully.

I stood by the bed and looked at her beautiful, regal face. 86-years-old and not a wrinkle. While I gently stroked her hair her breathing slowed, slowed, slowed. Four times per minute. Twice per minute. Once per minute. The pulsing vein in her thin neck slowed. Weakened. Faltered. And then…. she was gone.

Now she’s on the other side, with her three children who died before her. With her husband, most of her friends, her parents. With our first child.

In loving memory,
Grandma Mary, a.k.a. “Big Grandma”
04-05-21 to 04-20-07

ParaPump’s Pal

Mail? For me? I wonder what it is? Did I buy something on EBay that I forgot about? Let’s see, it is from “Distribution Center” in Stratford, Connecticut. Hmmmm….a mystery package. Ripppppppppppppppppppp!

Oh, cool! My cable! My cable came! Now my ParaPump can talk to my computer and visa versa! Oh boy, oh boy, oh boy, oh boy!

Nice long cable, USB port, thank God, sooooooooooo many BG meters come with serial cables. Most desktops and almost no lap tops come with serial ports nowadays. On the other end is a funky little plastic… well, I don’t know what to call it. Looks like a slice of a Roman aqueduct with a black test strip stuck into like Excalibur in the stone. In fact, it is a test strip of sorts. More on that in a moment.

I call up the PAL software that came with ParaPump. It takes me through several quick screens. Easier than easy.

Choose what you want to do. I want to back up my pump programming, so I select the option to “read” the pump. I could also have read a file, created new pump settings, printed a copy, and so forth. Oh, by the way, don’t spend twenty minutes clicking on the icon on your main menu and swearing at your mouse. If you look carefully, it says “To read the current settings from your pump, select the pump read button from the toolbar.” Then it shows you what the icon looks like. Yeah. Don’t click there on the main menu, do what the instructions tell you to do, click on the read button from the toolbar.

You’ll get a quick check list: Stop any funky deliveries (such as temp basal rates or square waves and the like). Enter the pump’s serial number into the software. You find this on the back of the pump or on the pump status screen, towards the bottom. Mine happens to start with 411, I like that. Make sure the meter is off. Plug the USB cable into the computer, and plug Excalibur directly into the BD's test strip port. Oooooooooooooooooooo. It glows blue! The BD logo on top of the aqueduct glows blue! Further proof, not that I needed it, that MedT has stolen alien technology to make this system work.

Tell the software to read the pump. You’re advised it could take 20 seconds. That said, very quickly the pump vibrates (I gave up on the mousey alarms and I’m trying vibrate) and temporarily suspends. The pump downloads very quickly, and then the Pal turns it back on. Your done. In front of me is my basal pattern. I can also view my bolus setup, bolus wizard, utilities, and sensor settings. Programming directly on the pump was pretty easy, but I’m guessing it will be easier to make changes on the computer, and then download them to the pump. Besides, God Forbid you should get hit by lightning and lose your pump memory, this’ll be a quick fix. This is pretty slick. All of the menus are simple and clean. Nothing fancy. Utilitarian but competent. Almost anyone could use this software. I say almost anyone, because somewhere there is probably someone who is such a big idiot….

Speaking of idiots, it might be me. I closed the program without saving the download and now it is gone. Gotta do it again…

WARNING: save your cotton-pickin’ download from the File menu. It won’t do it by itself!

So this is pretty s-l-i-c-k! Now the #$%@& BD meter has a purpose. But I’m still steamed that I can’t really use it much, at least not as designed/intended/advertised due to the sensor calibration issue.

Next time: CareLink

PS: sensor is behaving beautifully now that she’s not getting too many finger sticks.

Fatal flaw?

A great number of folks who’ve tried CGM get frustrated and give up. Why is a bit of a mystery; people tell me “the damn thing isn’t accurate.” Well, the damn things are accurate, but in the real world something is going wrong. At least where the ParaPump system is concerned, I think I know what it is. And the news could be better.

From my own experience in the CGM world of hard knocks I know that calibration makes or breaks you. I’ve found that for the smoothest running and most accurate sensor runs I need to limit calibrations to three per day, all at times when my BG is as stable as it ever is. For me, at least, the best times are when I first rise in the morning. Actually just before that, when I’m lying in bed thinking, ‘Oh God, it can’t possibly be morning yet…’ Then at about four in the afternoon and again at bedtime. I do three ‘cause the system requires you to go every 12 hours and I don’t have two periods of stable BG 12 hours apart. Also, living by the clock that much would drive me insane.

By the time my transmitter kicked the bucket the Girl was running so accurately I could have easily bloused by her. I didn’t ‘cause I’m not an idiot. But it was that good. I figured the next generation would be even better. Wrong. ParaPump has been all over the map and wildly inaccurate the last couple of days. Sometimes 100 or 150 points off.

Reminds me of my first weeks on the Guardian. When I was over-calibrating on storm-tossed seas. Of course, now I know better. But ParaPump doesn’t. All BGs sent from the Link are counted as calibration sticks. No choice allowed. The system is forcing me to take calibrations I know are bad.

Is there a solution? Yeah. But it sucks.

Once again ParaPump makes me choose: ease of BG entry for all purposes (meal, corrections, and calibrations); or a smooth running CGM. Well, duh, the choice is clear. But that doesn’t mean I’m at all happy about it. The software should have been set up to allow you to send BG from the Link Meter to the B-wiz without also sending that info as a calibration stick to the sensor.

I’ve found that if I manually enter a BG into the B-wiz it will ask me “BG to update sensor?” So there is a workaround. If I never use the BD Link, or if I choose to use it and turn off the communication, and enter all BG numbers manually I can whip the sensor into place. Damn shame, although it lets me use any or all BG meters I want. Still, I’m bummed, because I was really getting fond of the BD meter.

So I have a couple of choices. I could only use the BD Link for calibration and for downloading data from the pump to the computer. Or I can use some other meter all together and enter all my BG’s manually; both for calibration and insulin operations. As I’ve never had to do that, even on my CoZmo, it seems tedious at best.

A damn shame to have such an elegant concept smashed on the rocks by such a bizarre programming oversight.

Now we have a system that is no longer a system. Damn, damn, damn and shit too. I loved the fact that all these pieces of equipment were designed to play nice together. This pisses me off the way computer problems do. You know what I’m talking about, right? You call tech support and get a guy in India who can barely speak English, and who tells you it is a software problem, you call the software guy, (also in India, probably in the next cubical) and he says, no, I’m so sorry sir, it must be the hardware…

So the ParaPump plays nice with the BD meter. And the ParaPump probably plays nice with the sensor. For that mater the Sensor and the meter play nice together. You just can’t have all three of the kids in the room together.

Next: I going to tell the pump not to take calls from the BD meter. I’ll enter all BG by hand, damn it, and see if I can whip this sensor into shape. I’m sure I’ll succeed. But I’m still not happy about it.

Dark clouds on the horizon

(to a tune you all remember from a long time ago….)

The weather started getting rough,
The tiny ship was tossed.
If not for the courage of the fearless crew,
The Minnow would be lost; the Minnow would be lost.

What? Didn’t any of you watch Gilligan’s Island when you were kids?

The sensor is NOT behaving and I’m getting pissed off. I had my Guardian running pretty damn smooth at the end. ParaPump is giving me dejuavu of the bad old days when I first started on the CGM and had a lot of accuracy problems. Only difference is that now I’m smarter. Both Guardian and ParaPump use the same sensors. If there is trouble a foot, it is in the receiver, ‘cause I know the sensors really do work. But why would a newer and presumably superior unit be worse than it’s forbearer? I got so frustrated today between the wildly insane opinions of my BG that ParaPump was offering me and her mousey quiet alarms that I tried to hook up the girl to the new tiny transmitter. I was thinking I could maybe beam data to both units and run them side-by-side to sort out what is going on. Alas, although the transmitter ID numbers have the same number of digits, it is clear that my beloved garage door opener isn’t taking calls from this sexy new transmitter.

I guess that means that all original Guardians in the field are destined for retirement. (Taps playing mournfully in background.) There is also a new Guardian in town, though I’ve not met her yet. Saw her picture, she looks a heck of a lot like ParaPump. Twin sisters, it would seem, with just slightly different makeup.

So back to this BG debacle. I’ve got high alarms going off (when I can hear them) when the fingersticks say A-OK. I got fingersticks revealing lows when the ParaPump says I’m at a perfect 110. My blood pressure is going up…well, thanks to the ACE inhibitors for my kidneys, my blood pressure seems to stay down pretty much no matter what, so it is more correct to say my metaphorical blood pressure is going up.

Then, quite by accident, I discover what I believe is the root cause of the problem. It seems that all BG fingersticks taken by the BD Link Meter and beamed so slickly to the ParaPump are counted as calibration sticks. I’m hugely depressed. I had assumed that only finger sticks that I piped in through the sensor menu would count as calibration sticks, but I tested the premise today by checking the next Cal Due time on the sensor status menu and then taking a routine finger stick from the home screen. Then I checked the sensor status again. Next cal due 12 hours. Damn! Based on my experience, if you stick to a small number of calibration sticks and do them only in calm water, the sensor is pretty accurate. If you give it sticks when things are changing rapidly you are asking for accuracy problems. Of course when we most need to do fingersticks is when there is trouble. So it looks like any rapid change sticks or meal sticks or whatever are going to mess up the sensor. I guess I could only use the BD for Calibration…but that kind of sucks….nice feature is that you don’t have to manually enter all of your BG data. For that matter, if I did enter a stick manually would it also go straight to calibration too? Does that mean I have to choose between the bolus wizard and the sensor? Arrrrrggggggggggg!

There has got to be a way to turn this off! The best running sensors are one’s that only get three fasting finger sticks per day. The last fingerstick in the world you’d want to use to calibrate a sensor is just before you eat. Or when your sugar is surging up or down. Basically all of the times you’d want to use a meter for a fingerstick, right?

It seems too stupid a flaw to possibly exist. No one in their right mind would develop an integrated system that forced users to apply bad data, right? I will do more research, and God help me, call the help line if necessary to get to the bottom of this, then I’ll report back.

Why I won’t win the pie eating contest, but the guy with the CoZmo will

Let’s eat! First, like all good diabetic citizens, test…don’t guess! (Free plug for D-Life). Strip out of vial…oh damn, they all fell out. The disadvantage to having that tiny little canister. Pick up strips from floor and counter top. Put them all back and remember that you still need one to test. Try carefully for one, get three. Put two back. What was I doing?

Oh yes. Test…don’t guess. Insert strip, BD Link meter wakes up. Confirm code 19. Stab finger, get tiny drop of blood. Touch to strip….zipppppppp! Meter counts down 5… 4… 3… 2… .1 and the winner is: BGL of 160! Meter flashes and the number floats through the air. The ParaPump chirps. Now, press the B-for-Bolus-Button on the pump. 160 flashes at me, the BGL the Meter just revealed and sent to the pump. Ya gotta press ACT. Now ParaPump asks for the carbs. You arrow up, one gram at a time. That’ll encourage you to eat low carb meals. It goes faster and faster as you hold the button down. Next an “Estimate Details” screen comes up, detailing:

Est total--this is how much insulin the B-wiz thinks you should take.
Food intake—this is the carb number you just entered a few seconds ago.
Meter BG—this is the number that was just beamed over that you had to confirm.
Food—in units, this is the part of the estimated total bolus that is covering your carbs.
Corr—in units, this is the part of the estimated total bolus that is for correction.
Active Ins—this is how much insulin is still “in play” from previous boli or corrections based you the duration of action you set.
ACT to proceed
ESC to back up

Of course all of this doesn’t fit on one screen. Ya need to do some scrolling.

Let’s assume you agree with the B-wiz, or are too tired of watching your food get cold to care. You press ACT. Ha! No insulin yet! Now you must choose Normal, Dual, or Square wave bolus. If you choose Normal you still don’t get insulin. If like me, you like to have the pump remind you to check your BG in a couple of hours after a bolus you must go through a BG reminder screen each and every time you use the B-wiz. It does remember what you did last time, but it is still another step. Then at last, you can deliver the bolus, right? Well, no. You need to confirm the delivery volume, again. Then it delivers. One speed fits all, slow but that’s OK with me, I don’t like fast infusion anyway. But wait, what if you wanted a Dual Wave? Oh yeah, then there are more steps to go through.

So you MedT pumpers are saying, yeah, OK…so what’s your point? And anyone on a CoZmo pump is laughing their ass off right now.

Here is the CoZmo routine. You take out a test strip. Still possible to drop them all on the floor, but even the fattest finger fits inside the ridiculously over-sized FreeStyle canisters. You have to wake the pump up by pressing any button and then slip the strip into the CoZmonitor, which sits piggy-back on the rear of the pump. When you put the strip in, the meter software wakes up and takes over. Confirm code 17. Stab finger, get much larger drop of blood than they claim you need. Touch to strip….zipppppppp?? No preview window on a Freestyle test strip. Meter is also fast, but there is no countdown. How long it takes depends on how high or low your BG is. If the pump vibrates in your hand as soon as the blood hits the strip you know you are in deep, low trouble. If it takes a looooooooooooong time you know there is a correction bolus in your future. Our 160 shows up on the screen. You have a couple of choices, meal bolus, correction bolus, or just back to home screen. BTW, a CoZmo can be left on any number of its useful info screens, rather than returning to the blank home screen that the ParaPump does after 30 seconds. I always left my CoZmo on the IOB screen. That stands for Insulin On Board, and it tells you how much bolus insulin is in play. Handy thing to know when you look at a BG reading. If you have 5.8 units on board and your BG is 112, you have a problem.

But I digress. So in this case you’d select meal bolus. If you have various types of boluses programmed in the next screen asks you to choose. Next you dial in your carbs, by five unit jumps. It asks if you want a correction bolus. If you say yes is shows you the BG result you just got. Then it shows you the corrected (up or down) bolus and you press deliver.

All of these actions are done with the right-hand button. You can rest your right thumb on the button and fly through the procedure in no time at all. And it never asks you about reminders. If you’ve programmed it for reminders from the get-go it just does it automatically.

Let’s see…writing about it takes more time than doing it. How many menu screens did that take? 1…2…3… OK… Six total. The ParaPump sends us through eight… well, I guess that really isn’t that many more. Maybe it’s just the strangeness of a new way of doing business. In a month’s time I may be so use to this that I won’t give it a thought.

Maybe I’ll have a chance at winning that pie eating contest after all…

Sleeping with my new mistress

It is the biggest fear of all proto-pumpers. Not the insertion needles. Not the lack of long-acting insulin and the corresponding short cut to a DKA coma if the pump craps out. Not the fact you must test, test, test, test until your finger tips are a constellation of tiny black dots.

No the big fear is: how the hell do I sleep with this thing? When I was on the path to pumping I asked around the Insulin Pumpers Board, “How do you wear your pump at night.” The most common answer was, just throw it in and dive in after it.

That always sounded crazy to me. For a long time I’d clip the pump to my sleep shirt. When I got the girl I put her on the night stand, but lost telemetry too many times. In the end I clipped the two belt clips together, tossed the pair of them into the bed and let the infusion hose pull me in. Sort of like a crab fisherman being snatched off the deck when a rope catches his foot. Only with a better ending.

I frequently end up in the morning with the hose wrapped around my body, my arms pinned. Held prisoner by hostile Indians. Insulians? Hehehe.

So after the sad Valentine’s day break-up with the girl, I was just sleeping with the pump. Where is my wife, you ask?

Well, I’m embarrassed to admit it, but a while back she left me for another man. Hard to blame her, her new guy is handsome, smart, funny and charming. He’s also five-years-old and my son. I never know where I will find my two night-owls when I get up for work in the morning. Sometimes asleep on the couch, Pink Panther DVD still running. Other times in his room. Sometimes in the back bedroom.

After several months of this nonsense I tried to explain to Rio that in the normal course of events a child’s mother sleeps with the child’s father. He gave me that my-poor-father-is-deluded-and-must-be-suffering-from-low-blood-sugar look.

The next day he came to me and said, “You can have Mommy back when I grow up and get a wife of my own,” then he hesitate and added, “of course, you’ll be dead by then”

So as I’m getting ready to go to bed all by my self on the first night with my new system, it happens. For the first time since I hooked up, the ParaPump unexpectedly speaks to me.

Be, bee, beee, beeee. Soft. Like a gentle breeze. Four soft, short, musical tones. Each one an octave above the previous. Like a child’s music box, but the entire stanza less than two seconds. Then nothing for a full minute. Then the whisper of music repeats, be, bee, beee, beeee. You gotta be kidding me. That’s an alarm?

I miss the Nazis-bombing-London-air-raid-siren racket of my Guardian. Now that was a noise that got your attention. And it was loud. I wonder if this gentle music will wake me up? I’m guessing that the ParaPump will have a similarly disappointing low alarm noise. The crew at the clinic learned to recognize the distinctive cork-screwing low alarm and air-raid high alarms of the Girl. At a low nurses would coming running with juice, and a high my colleagues would point fingers and tease me, “what did you eat this time?”

I know from my homework that there is a backup alarm. I don’t respond to my first high alarm to see what the backup siren will sound like. I get the two seconds of music every minute and then, ten minutes into the game, it goes off: wee-wea-wee-wea-wee-wea-wee-wea-wee-wea-wee-wea-wee-wea-wee-wea-wee-wea-wee-wea-wee-wea-wee-wea-wee-wea-wee-wea-wee-wea. It is much louder, but still not as loud as the original. But it does go on for a nice length of time. 15 or 20 seconds. Presumably it would repeat, but I go ahead and silence it.

Ten minutes before the loud alarm. Ten minutes is an eternity during a nighttime hypo. How far would my sugar drop in ten minutes if a fast-moving hypo hit? The dreaded hypolanche (named for an avalanche). I’d be a hell of a lot happier with four normal alarms and then throw in the big guns. Or better still, a progressive alarm, each louder and longer than the one before it.

Did I read the ParaPump will also vibrate as backup? Or does it make noise if it is set to vibrate and that doesn’t do the trick? I don’t recall.

This is a big disappointment. Guardian could both make noise and vibrate, and it was a good thing too. Sometimes in a noisy place I wouldn’t hear her, but I could feel her. On the flip side, sleeping, sometimes I wouldn’t feel the vibe, but I’d sure as heck hear her. This rotten ParaPump is making me choose. Vibrate or Noise. Noise or Vibrate. I can not have my cake and eat it too.

While I’m griping, I’m also disappointed that the BG graphs can’t be used as home screens. I discovered today that they timeout, not as fast as other screens, but in about 30 seconds. I had envisioned being able to leave the graph on so I could glace at it and see where I’m at. Granted, it is only one button to press, but….well damn.

Speaking of Graphs, they are not as useful yet as I had hoped. The 24 hour screen is just too small to be useful, and the three hour always looks like a flat line. Your sugar really has to surge or plummet to show at all, given the horizontal vs. vertical displacement of the graph. My entire “between the lines” range of 75 to 200 is only a quarter of an inch on the screen. Still better than no graph at all, but we only get 3 hour or 24 hour. What about six, or eight, or ten, or twelve?

Anyway, it is late, and morning is earlier than I want to think about. I toss the new ParaPump into bed and dive in after it. I’m paranoid about the alarm volume, so I pull the pump up under my chin, to be closer to my ears. It takes me a minute to realize it: I’m lying on the transmitter. I’m on my side, the transmitter is buried in my mattress and it doesn’t hurt! The old Guardian transmitter was so big that if I rolled over on it at night it would often wake me up. If it didn’t, the lost signal alarm would.

Wow. This is a lot more comfortable. How strong will the signal be? Worrying, I find my self turning on the night light every couple of minutes for the next fifteen minutes, each time greeted by the little un-lit Olympic torch icon that tells you the signal between the ParaPump and the Seashell is strong. Reassured, I drift into sleep…..

Three A.M…..

Wee-wea-wee-wea-wee-wea-wee-wea-wee-wea-wee-wea-wee-wea-wee-wea-wee-wea-wee-wea-wee-wea-wee-wea-wee-wea-wee-wea-wee-wea.

What the fuck? What’s that? Through the fog of exhausted sleep my brain is trying to grasp what is going on. What is this new noise? Where the hell am I? Ummmm….wait a sec….Who the hell am I? Then like a slow motion reverse film of a vase of water un-breaking and reassembling its self, the pieces of my life start coming back together, sorting out the dream world from the real one.

I fumble for the source of the noise, find the infusion set hosing, and reel in the ParaPump. Fingers fumble over unfamiliar buttons to turn off the alarm.

A low. I sit up and turn on the red-lens mini flash light that lives on my night stand. I take a finger stick. 88. I had ParaPump set at 85. They are pretty close. I hit ESC to bring up the three hour screen. A slow, gentle descending arc is displayed. I look for the IOB screen to see if there is any insulin left in play in my body, and then remember: that was CoZmo. No quick and easy way to determine your Insulin On Board with the ParaPump. I squint at the ceiling, where my cool Christmas present clock from Rio’s baby sitter projects the time and out door temp. A little after 3am and damn cold outside. No chance of left-over bolus insulin causing trouble tonight.

Then it dawns on me. I was woken up not by Be, bee, beee, beeee. But by Wee-wea-wee-wea-wee-wea-wee. I slept right through the dainty low alarm. All ten of them. It was the backup siren that woke me up. I wipe the sleep goop from my eyes and check the alarm history. Yeah. Shit. The Low alarm is shown to have gone off ten minutes before. Lucky for me I was just skating on thin ice, not really falling though into the icy waters of a real hypo below.

Why the sam-hell don’t we have a volume control on this thing??? Why can’t we have both noise and vibe? I wave of depression washes over me. Six weeks of stress with no CGM coverage and now I’ve got it again, and it doesn’t do the job well. But then, sitting on the edge of my bed in the red glow of my flashlight, bare feet getting cold on the floor, I reconsider.

On the first night on the job, ParaPump has done what she was designed to do: Watch,
Detect, Warn. And we are just getting to know each other. So much to explore with a new relationship. And one other thing I can tell you, from just one day, I LOVE just having one box on my belt. It is liberating and wonderful. Pump and Guardian together. The pump is different, I need to get use to it. I’m sure there will be things I hate and things I love, but having everything you need in one box…and a smaller box than either of the old boxes….well, that’s just…

Well, that requires some sort of adjective that the brain cannot summon at a bit after three in the morning. I turn off my red flashlight, slip my ice cold feet back under the covers and snuggle up with my new mistress.

Pumping?

Well….I think I’m pumping. But how would one know, really?

The ParaPump seems happy. No little circle icons, white or black, to indicate trouble. No squeaks, squawks, beeps or boops. All is quiet on the Western Front.

I’ll take you through the hook-up process step-by-step some other morning, but here are some quick observations today, my first Medtronic hookup. It seems to me that Medtronic makes us go though quite a few more steps to do just about everything than the other guys do. But, I’ll really need to sit down and count the various steps to be sure, it may just be that things are different so it seems harder.

I put in the sensor first, as the new books from MedT say to wait five minutes before hooking up the transmitter. I decide to push it in myself, rather than use the inserter. Seems to me that sensors failed more often after being snapped in, than when I did it manually.

Next I fill a reservoir with NovoLog. MedT has a really clever little device on the end of the reservoir that holds the insulin vial in place. I really like that a lot. In fact, they have a lot of idiot proofing technology, which I appreciate, as I’m as big an idiot as anyone else. Which brings me back to why do we have idiot-proof machinery with rocket-scientist menus? More on that later…

I choose the Paradigm Quick-set in 43” hose and 9mm canaula. Unlike my old Comfort sets that went in at a 45 degree angle, these go straight in. I’m pretty excited about that, because I’ve been having some bizarrely different BGL responses to same-food, same-bolus situations. There are a couple of studies that suggest the straight-in canauls infuse the insulin more repeatabley. We’ll see!

Also, I feel, with no evidence what-so-ever to back it up, that the straight-in will cause less tissue damage. Less scaring issues. However, one nice thing about the Comfort set that I’ll miss is that the package is thin, thin, thin. Easy to carry a spare “just for incase.” The MedT package is quite thick. Gonna have to re-configure my “go bag.”

I did use the serter to put in the infusion set. Worked great. Once I had the courage to do it. Funny, I know several MedT pumpers that had to replace infusion sets away from home, away from their insertion devices. Caused them much mental trauma to put one in by hand. I’ve put in God only knows how many sets by hand no problem but stood in my kitchen with my fingers on the buttons for about three minutes before I could get up the courage to squeeze them closed to fire the set into my stomach. In the end it was fast, totally painless. Wonderful, of course.

The set’s hub on my stomach is thicker—the hub is higher. No big deal really….just different. I haven’t tried a disconnect yet, it’s a rotate to unlock and pull affair. I’ll let you know how it goes.

Another new-for-me and very cool feature is the needle guard on the set’s guide needle. Once you pull out the needle you can snap shut a plastic guard that keeps you from sticking yourself, your spouse, your child, your cat, or your garbage man. The International Brotherhood of Trash Collectors will thank you.

So anyway, as far as I know the insulin is dripping, dripping, dripping into my subQ space on my right side; about four and one half inches from my belly button. Funny, I’ve been pumping for what seems like forever, but always with the same pump. I took it for granted. Never gave it a moment’s thought as to whether or not it was working. I live, therefore I pump.

Now with a new style of infusion set and a new pump, I feel a creeping sense of paranoia. Is it working?

The sensor is on her two hour warm up, so I’ve got no BG data flowing yet either. I do a finger stick to make sure I’m not on the DKA express. I plan a couple of more, just for in case.

Two hours later…. (French Accent a’la Sponge Bob)

Huh… I should have received the “BG now” message to calibrate the sensor by now. I wander through the Menus seeking more information. A five-year-old lost in the mall. There aren’t that many menus…. Have I been at this one before? I’m dropping mental bread crumbs as a go along blindly with a male’s typical stubbornness not to just get out the damn manual and look it up…

Eureka! I find it under the Sensor Status screen (ESC button four times, for what it is worth), and I didn’t have to resort to checking the manual. And the next Calibration is due….huh? Oh. Still 45 minutes off. Maybe the new system takes longer? Darn. Oh well, not really that big of a deal. Guess I’ll balance the check book. Or maybe I’ll have another cup of coffee…the check book has waited three years to be balanced, another couple of days won’t hurt.

45 minutes later….

The appointed time for our calibration date has come and gone. I check the sensor status screen to find that ParaPump had changed the time of our date. (I guess ParaPump is female after all). Huh. I did get a couple of sensor error messages in the last hour. I’ve also had some telemetry trouble with the seashell transmitter, which I think I fixed. The ParaPump is on my belt, above my right hip. The sensor is implanted in my right leg, about mid-way between my hip and my knee. Roughly between them is the metal folding box cutter that I wear as a pocket knife. I wondered if all that metal might have some how screwed up the transmissions. I moved the knife from it’s usual home, clipped into the top of my right jeans pocket to a new home on the left side. No more signal trouble. Did the knife cause it? Don’t know, but looks suspiciously like probable cause to me. Hence forth knife will have to dance on the opposite side of where the ParaPump crew is on a given week. New estimated calibration time, ten minutes.

10 minutes later….

This is not looking good for the home team. I wonder if I’ve got a bad sensor insertion? If they bleed when you put them in, you might as well rip ‘em out and start over. They almost never run smooth if it is a bleeder. I didn’t see any blood, but…. ParaPump says she’s almost ready, will I come back in five minutes? Yeah, OK, I waited this long for our date, another five minutes won’t kill me.

Five minutes later…

This is a little like trying to take my wife out for dinner. I put the CGM sensor in at about nine this morning or so. I expected a steady stream of BG data to start rolling in by 11am. It is now almost 1pm. Parapump asks for one more minute.

Official countdown on the Girl was 2 hours, 20 minutes, but she always got to the party early. ParaPump, on the other hand, seems to be on Navajo Time. I’ve resorted to actually looking at the manual again. The manual for the new sensor says the initialization period should be two hours, so my sporty new mistress should be even faster than my old one. Well, isn’t that the point of getting a younger mistress, after all? So what’s up?

OK, I’ll wait at the door.

One minute later…

Can you come back in one more minute? Again? OK.

One minute later…

Can you come back in one more minute? You’ve got to be kidding me! OK, I’ll be back.

One minute later…

Can you come back in one more minute? How long can this possibly go on? Is there some sort of malfunction? Should I try another sensor? Should I just wait until the end of the day and see what happens?

One minute later…

Can you come back in one more minute? Again? You’ve got to be F’en kidding me! No! I will not come back in one more minute, Sam-I-am, I will NOT eat green eggs and ham!

Beeeeeeeeeeep. BG Now.

Oh for Christ’s sake….OK out with the BD Link meter (which I’ll come up with some catchy nickname for later on). Lets get this show on the road! Let’s get this integrated system integrated!

Oh, by the way, my BG is pretty good. I’m not DKA or even on the way. I guess the pump is working! Pump I can, pump I can, pump I can. Whoo, whoo!! OK, I guess I’m spending way too much time with Rio’s books….

Magic

The problem with magic, of course, is that it is difficult to discern black magic from white magic. I’m sure no one would argue with me that the BD meter is absolutely magic. No question about that. The argument comes in over whether it is good or bad magic.

I’ve got to tell you. The first time you check you BG with it, watch it flash and then see the same number appear on the screen of your pump….it is mesmerizing. I was so taken with it I ran and got Deb and Rio and did another finger stick so they could see. Deb was blown away too, the little one not so much so. At five years old, the world is packed with magic. Of course BG meters send data to pumps. Can I go back and watch Sponge Bob now?

The BD meter has more bad press than almost any other modern functional diabetes device. Where there is so much smoke there must be some fire. Maybe I’ve got a new-and-improved model. Or maybe I just haven’t used it enough to see its dark side, but so far I actually like the thing.

Every day I get to use the following test strips: Accu-Chek, FreeStyle, OneTouch, and Precision X-tra. At least once a week Bayer Contour, and now and again odd-balls like Tack Ease and the like. This was my first contact with the BD. Gotta say, I really like the BD test strip. I’ve already covered how much I like the little tiny canisters, but it is the blood sucking part of the test strip that is really blew me away. Like all of the above, except the FreeStyle, the BD has a preview window that allows you to observe the blood-flow and fill-levels into the strip. The BD is the fastest wicking strip on the market except for the Accu-Chek. The damn Accu-Chek is so fast that if you don’t have the strip lined up with the blood drop just right, the meter will start testing before being full. Then it gives you an error message while stealing another dollar from your wallet. People more paranoid than I am have suggested that this design “flaw” is intentional, to sell more test strips.

I digress. The BD is fast, uses a very small drop, and always for me so far, fills right. One worry I have is that the strip is short and the port shallow. The strip has a lot of wiggle room. Will that effect accuracy?

I decide to compare the BD to a couple other meters around the house. I gather up part of the collection and put strips in each of their little mouths. Next, time to lance. Click. Snap. Squeeze. Damn. That is not nearly enough blood. Got to be quick, these puppies will time out. The little finger is the most tender. Click. Snap. Ouch! Son-a-bitch! That hurt! Squeeze… ah, nice big, big, big drop of blood. To the meters, which now look like some sort of swarm of vampire bats clustered around my finger. Give them each a sip of blood in turn….quick! Write the numbers down!

Well, the BD’s accuracy seems no worse than any other meter. Checking three BD strips in a row I found: 151, 143, 155 all from the same drop of blood. That is an extraordinarily tight spread. Most strips have up to 20% spread. Assuming the “real” BG was 150 we could expect a 30 point range, so this is pretty sweet. I’ll run a HemoCue comparison at the clinic next week, and let you know how it stacks up. (The HemoCue is a lab instrument we use for Dxing diabetes and checking meter function, it is super-accurate to the point of being the last word in testing. But it is big, and slow, and takes a lot of blood--which is why I haven’t stolen it.)

So if the strip platform is really as good as it looks at first glance, how did BD blow it? My theory: well, I’ve never seen a BD rep. Have you? I see BD ads in magazines, they look like what you’d expect an enema company to have published in Life Magazine in 1951. The way to sell test strips is to give meters to diabetes educators, clinics, and doctors; who in turn give them to diabetics. You need presence to get sales. BD seems to have had no presence.

I’m beginning to wonder if BD stands for Big Dickheads. Here is a company that just doesn’t seem to know how to market it’s stuff. A shame, cause I’m thinking this device may not deserve the bad rep it has, and it took all BD meters and strips down along with it. Or it may be like Firestone, a fine company that made a bad product and then handled it poorly.

Other gripes so far on the BD, no back light that I can find. Not like diabetics need to check their blood in the middle of the night or anything…

On an interesting side note, the BD meter is also used as a translator between the pump and a computer. The pump talks to the meter, the meter talks to the computer, the computer talks to the internet, and the internet talks to MedT’s servers where CareLink lives. The knee bone is connected to the shin bone, the shin bone is contacted to… Of course for all of this you need a cable that I don’t have yet. Oh well, its just as well to have a week or two of data to look at before we dive into software anyway.

So the jury is still officially out on the BD Link. It is an amazing concept. It seems to be working for me so far, but I know way more people that hate it than love it. I suppose there could be some sort manufacturing issues. Lemons and Gems? Did I get one from a good batch? Or are they better now? Did BD quietly make changes? Or do I just need more time to see its dark side?

MedT pumpers, check in with your votes. White magic or black magic?


Tomorrow: let the insulin flow! Well, drip, if you want to get all technical about it…

Homework

I’m eager to get started, but first things first. I gotta learn the rules of the road before I jump into this mustang convertible and head out. I got to the clinic early and my first patient was late, so I got in 17 minutes of reading time. Then, I studied Quickserter instructions in the bathroom between consultations. The instructions are a cartoon that takes up 15% of a over-sized tabloid sized sheet. The rest is taken up with legal warnings in, I swear to God, thirteen languages. “Never point loaded insertion device toward any body part where insertion is not desired.” Kid you not. Do you think the Medtronic lawyer who wrote that one surfs for porn on the company computers at lunchtime?

It also tells you to be sure to remove the needle guard before sticking the needle into your skin and mentions in passing that if you shove the needle into your eye you might go blind. What it doesn’t really tell me is how to put the damn set in. Well, this part isn’t rocket science. Between the cartoon and my previous experience, not to mention a tiny bit of mechanical intelligence, I think I can figure this much out.

The sensetter instructions are of similar cartoon ilk. On the other hand, the minimalist approach was not taken with the ParaPump manual. All 160 pages of it. Plus a 58 page Sensor Features User Guide, a 12 page Pump at a Glance booklet. Twelve pages of anything is more than a glance. Someone who still reads Playboy should count how many pages of photos the centerfold gets and report back in comments. There is also an Introduction to Insulin Pump Therapy, 30 pages. And of course the Practical Guide to CGM, which I haven’t read yet ‘cause I’m still sulking.

I read the intro first. It is geared towards newbies. It’s got that horrid photo of the couple on the scooter motorcycle on the cover. Remember that one from the Now I can! campaign? Only this time, like the pizza on the ParaPump box, someone just got their first copy of Photoshop and can’t resist mixing photos and clip art. The red and white scooter has been turned into clip art. Anyway, the booklet is harmless and probably helpful to those who are new. I don’t recall Smith’s sending me anything like that with my first pump, and it would probably have been nice to have a Pumping 101 text. It has little text sections with mini-quizzes. Nuff said.

At lunch I drank an Atkins shake… (5 net carbs – 4 fiber = 1 net impact carb, right? Ha! Trick question. You don’t take fiber off of meals under five carbs. If you don’t believe me just see page 20 of the Intro to Pumping.) …and plowed deeper into the books. In the early afternoon one of my home visits to a terminal patient got cut short. No, not like that, so I holed up in my office and got some more book time in. I considered reading on the drive home, but as I was driving it didn’t seem prudent.

I finished over dinner.

The pump at a glace was baffling until I had read most of the manual and skimmed the parts that made more sense with pump in hand. My advice: use it for pump-in-review instead of as a getting acquainted tool.

The main manuals are about what you’d expect. Not great. But not terrible either. No humor. Not always clear, other times insulting. They are full of flow charts and black-and-white drawings. Surprisingly, the best medical device manual I’ve even seen was the beauty that came with the retched GlucoWatch. Horrid device, wonderful manual. All of that said, the Medtronic Manuals are OK. They get the job done.

After dinner I sat down with my little ParaPump, put a battery in and got to programming it. Once I got the hang of the Medtronic menu system it was pretty straight forward. My only initial complaint is it looks like I’ll have to take quite a few more steps to accomplish things like….oh eating… than I did with the CoZmo. But, we’ll see.

I just plugged in all the same numbers I’ve been using from my current pump. I got my 18-step basal pattern in with no trouble, ran out of space for insulin sensitivity (max 8 steps in day). Damn. Well a little averaging….Programmed the pump to recognize the BG meter and the sensor transmitter when they knock on the door and set up the “Bolus Wizard.” The Bwiz is a software that looks at BG, insulin already in play, your targets, sensitivies, carb ratios and whether the moon is in Leo or Scorpio and then recommends a volume of insulin for delivery. More on that on another day.

BTW, kudos to Medtronic’s wizards for shipping the pump in screw-around mode. Well, I’m sure that’s not what they call it, but your new ParaPump arrives set up so you can explore at will. Once you initiate a “rewind,” which is part of the loading of a new reservoir you cancel screw-around mode and you are into honest-to-God pumping.

Of course in addition to the manuals there is a blizzard of various warranty sheets, wallet cards, and other lose bits of paper.

So….it is well after midnight now, but little ParaPump is fully programmed and waiting. I’m gonna hook up in the morning. Then I’m going to put in a sensor. It’s been a while, all the hair on my legs grew back! But I started shaving it off a few days ago and I’m ready. So ready. Ready to watch the flow of the water again, rather than the stones in the stream. To use the crystal ball. To be in a red state. To celebrate defeat and to be the lion tamer.

And I’m ready to do all of that with one box on my belt and to be able to watch the bizarre alien twists and turns of my BG trace on this little blue screen. This time, in real time.

Many boxes

Stay calm. Schunnnnnnnnnnnnnk! Razor knife slits open the brown shipping tape on the unassuming box. I gently peal back the flaps and inside is…..peanuts. Foam packing peanuts.

Stay calm.

Under the packing peanuts are boxes. Many boxes. Like Rio empting out his Easter basket last weekend I take each one out, one after another, barley glancing at them until all that remains is the peanuts.

Stay calm.

What do we have? First a book in an envelope. “A practical guide to continuous glucose monitoring.” Momentary flash of anger. How come they didn’t ask me to write that?

Stay calm.

The largest box. Blue and white with “Paradigm Real-Time” in large letters. A large photo of a smiling twenty-something girl in a denim shirt. Oddly someone has added a slice of clip-art pizza to her hands. Very strange. Also an image of the pump. We know what’s in this box.

The MiniMed Paradigm Real-Time Insulin Pump and Continuous Glucose Monitoring System is too big a mouthful, and even worse on the fingers. Even Paradigm Real-Time is too much for me. Besides which, I can’t even spell P-a-r-a-d-i-g-m. Hence forth on these pages I’m going to call it the ParaPump. So it is written, so it is done (apologizes to Yul Brynner’s ghost).

Also a box for the “Link,” what the rest of us would call a BG Meter. A box for the remote control. A box for the transmitter. A box for the Quick Serter, and of course boxes for the reservoirs and infusion sets. Oh, yeah. A DVD too.

Stay calm. Which to open first? No contest. The ParaPump. Off with the shrink-wrap! The top of the box slides slowly up, with just enough friction to create a delightful tickle of anticipation down my spine. Inside are….manuals. Lots, and lots, and lots of manuals. OK. I know how my lunch hour is going to be spent tomorrow.

Under the inch plus of spiral-bound manuals, nestled in clear plastic, like a precious gem in a velvet box is the ParaPump. Frosted plastic. Just a hint of high-tech innards show though the skin. Dark navy-blue keyboard. Four grey and white keys and a royal blue “ACT” key. One button to guide them, one button to bind them…(apologies to Tolkien fans).

The ParaPump is beautiful in the way a war-plane, a camera, or a gun can be. This is no I-Pod. It is built for function not form, and yet…to me at least, I love the form. It is no-nonsense, but not clunky like the garage-door opener Guardian I wore for so long. It has a certain sleek, modern, utilitarian, but futuristic look to it. Clearly a machine built to DO something. It doesn’t snub form, but is no slave to it. It’ll look just fine on my belt. My old CoZmo was designed to look like a cell phone, but only pumpers see insulin pumps anyway. Most people just don’t pay that much attention to other people.

Long time readers may recall that I’ve spent a great deal of my life working with various machines. Some are just machines. Some seem to have personality. Some seem female, some male, some have no gender. We called my Guardian “The Girl.” What is the ParaPump? Sorry, gang. I think it is just a machine, although it did elicit a “Coooooool” from my wife. Who also, with a quick feminine eye for weight said, “so much thinner than your old one.”

In a side pocket I find some more goodies. A hard-plastic holster-style belt clip. Oh JOY! This is the kind of clip Deltec cheated me out of years ago…also a second clip, a few mysterious accessories, and even brand-new, good until 2013 AAA Bunny batteries. I like it when you get the batteries with your toys.

I can’t resist. I pull the protective clear shipping guard out of the way and pull the pump out of the box. I rest it in the palm of my hand. Small, thin. Heavier than you’d expect. I run my left index finger lightly over its surface. Hello beautiful. Welcome.

Not at all the Calvary Soldier. Too small for a knight in shinning armor. Well, ParaPump, we’ll figure out what kind of animal you are later.

Next box: the transmitter. Now many of you might not of heard, but here is where there has been a true paradigm shift. Did you hear the two loud thumps last week? Like the dull thuds of sonic booms? Yeah, that was the folks a DexCom and Abbott falling to the floor in dead faints. There is a new CGM transmitter in town. It is not evolutionary, it is revolutionary.

I knew about it, ‘cause Medtronic had sent me (and every other customer, no doubt) a gaudy flyer about it. Typical bright, badly matched Medtronic colors (like lime-green and royal blue, grosssssssssssssss). FYI: there was also a flyer on the new and improved Guardian, and it looks to have most of the things on my wish list for the old one.

Anyway, back to the transmitter. Reading about it, seeing photos of it….no substitute for holding it in the palm of your hand. I kid you not. It is exactly one half the size of a pregnant poker chip. Yeah. You can not believe how fricken small this thing is. It weighs nothing. The damn thing must be filled with helium. This will take up no landscape on the sexiest of stomachs (not mine) or on the smallest, skinniest T-1 child. BTW: FDA approved these things for kids, a real blessing to parents of young T-1s.

Now as to the poker chip being knocked up, the new transmitter is thicker than a poker chip, but less than half the thickness of the old transmitter. What to compare it to? Three sticks of gum? Four dimes? But that would just be at its apex. It is smooth and sleek. Aerodynamic. The whole thing looks like a wave-worn seashell lying on the beach.

Now check this out: no wires. Yeah. You heard me. No wires. It clips directly onto the sensor. But I saved the best till last.

Sitting down? Stay calm.

It is rechargeable.

It comes with a ugly blue dock that holds a AAA battery. Ya plug the thing in and charge it up. According to the book eight hours buys you 14 days. Reminds me of those cell phone quick-chargers that save your bacon when you run out of juice. Once we get into real-world use I’ll report in on how to integrate the missing hours of coverage, but speaking as a guy who watched a non-rechargeable thousand dollar transmitter kick the bucket I gotta say this sounds like a huge improvement.

The seashell is cream colored. Why not flesh tone? Why not metallic? Does a cool color of plastic really cost more than a boring one? Oh well. Minor quibble. Can’t wait to wear this puppy!

One unexpected and cool thing happened when I slipped the transmitter out of the charger. Deep inside the shell a glowing green light started flashing. I’m alive. I’m alive. I’m alive. Morse code from beyond. I think the folks a Medtronic broke into Area 51 and stole some of that Roswell UFO technology this time.

Next the Meter. I’m really looking forwards to trying this thing out. I’ve heard a lot of bad things about it, but I know a few T-1s who swear on their lives it is the best thing ever. The meter is not as big or ugly in person as it is in its mug shots. It is also clear to match my ParaPump (well, OK, the pump belongs to Medtronic, but I can’t help but think of it as mine…). You can see the circuit boards through the back, without wearing your x-ray glasses you bought out of the back of a comic book. Meter case is not the worst I’ve ever seen or the best. A bit on the large side. Don’t know if I’ll want to wear that on my belt or not. I’ve been spoiled. With the meter attached to my pump I just carry a small lance and a vial of test strips in a small belt pouch. Of course if the ParaPumps’ CGM works as well as I was finally able to get the Girl to work I’m only going to need to finger stick about three times per day. Hmmmmmmm….well, one problem at a time.

You got to remember what I do for a living more than half the time, I’ve got practically every meter known to man in my office—so I have a lot to compare to. The lancing device looks like trouble. I’ll stick with the one I stole from a OneTouch Ultra Mini. Best lancer made. Short, cute, one-handed operation. Variable depth. Takes round or square lances.

What? No test strips? Damn. Even those cheap bastards at Bayer give a few test strips with their meters. A lousy five to be exact. Humph!

Well off to the pharmacy first thing I can…what else do we have? Hey! Why are there two bottles of control solution. Wait a sec…. Wait a sec… Ohmigod! Look at that! That isn’t a bottle of control solution, it is the smallest bottle of test strips I’ve ever seen! How cute! It’s like those little mini bottles of Tabasco Sauce the Army guys get in their MREs. And, what? 25 strips in this little bottle? Wow. OK, better take back all the bad things I was thinking and saying and typing. Ooooooooooo, the strips are gold on one side. So that explains the cost of test strips. They are made of gold, after all. HeeHeeeHee…

According to the box this is not your ordinary blood glucose monitor. It talks to the ParaPump and your computer too. Cool. Fun. Fun and cool. Cool and fun. If it works.

By the way, someone bought out the de-funct BD test strip biz, so the strips will continue to be available for Medtronic pumpers.

Next box, the remote control. Again, battery included. A truncated AAA. Never seen a battery that looks like this before. Energizer A23. Looks like a midget AAA. Remote is a smaller, thinner version of the thingy you use to lock your car. Beep-Beep! Not entirely sure under what circumstances I’d use this. I can see where it would be a necessity for a woman who wears her pump in her bra…and of course I don’t wear a bra and wouldn’t put my pump there if I did. Too flat chested. All of that said, I like having the whole system to play with. It may prove highly useful!

Another horrid clear-ish blue plastic device is the Quick-Serter, which I almost broke before Serting anything with it. Serves me right for playing with stuff before reading the directions! So the way is actually works is: you pull up on the top. Click! Then DON’T push back down on the top again. Instead, gently squeeze the little grey buttons on the side and SHUNK! the device flies down like a snapping turtle. Cool. I’ve been a macho insert-it-your-self-by-hand infusion set kind of guy. Now I can see how the other half lives.

I haven’t looked at the reservoirs and the sets yet, but it is late. Gotta get up early for the commute to the clinic, so I’ll report more later.

Good night all. Oh, yeah, and stay calm; I’ll be back tomorrow.