Conquering the Elephants….err….Elements

Sir Edmund Hillary and Everest. Admiral Richard E. Byrd and the South Pole. Charles Lindbergh and the Atlantic. Wil and the Fudge-fudge Walnut Brownie at the Elephant Bar in Colorado Springs. Yes, these are all epic tales of man versus nature; of overcoming insurmountable odds and succeeding. Of pushing human limits to the edge of oblivion.

Ever been to an Elephant Bar? They are wonderful restaurants, but not particularly diabetes-friendly. The decor is Africa, pre-World War II. Kaki, brown, beige and black. Zebra stripes and bamboo. Funky ceiling fans and giraffe patterns. Vintage travel posters from airlines that no longer exist. Fits my deluded self-image of being a Hemingwayesque world-traveling adventure-seeking journalist. There is even a life-sized elephant head on the wall, made of plaster. I boost Rio up so he can touch the tusks.

But the name of the restaurant has nothing to do with the retro-safari décor. I really is all about the portion size.

The Fudge-fudge Walnut Brownie (hence forth the FFWB to save space) comes in a zebra-striped bowl the size of your head. There are two slabs of brownie the size of your face. Scoops of vanilla ice cream in between and everywhere else. A gallon of hot fudge sauce. Enough whipped cream to camouflage an aircraft carrier.

But this is not an indulgence; this really all about science in action. I’m selflessly doing this for you, dear readers, with no thought of myself what-so-ever. Time to really put this new Guardian through her paces. I’m too lazy the look up the pump log, but I think I programmed 150 carbs on a combo bolus over three hours with 55% on the table. It wasn’t nearly enough.

So the new girl’s screen maxes out at 350. Above that you get a solid bar at the top of the graph. You’ll still get SG numbers for a little while. Until 400. Then you only get a message that says “above 400.” Could be 401. Could be 550. Could be 800. Who knows?

In all fairness, if you’re diabetic, you really don’t belong up in these rarified numbers. In all fairness, most meters crap out at 500 too. I didn’t stay above 400 for long; but every two hours I got a high SG alarm, even though my blood sugar was dropping steadily. Both high and low alarms feature a “snooze” feature. This works just like a snooze button on an alarm clock. It lets you sleep a while even while the alarm condition continues to persist.

I’ve set my high snooze to two hours. If I’ve eaten a FFWB in the interest of science, I know I’m going to be high a while. It took about 4 correction boluses of various sizes to get me “between the lines,” back to my target BGL. You can select your snooze length. With the duration of action of NovoLog being around four hours in my body, I find the two hour to be a good choice. I don’t get “bugged” constantly, but the system checks in with me every couple of hours and reminds me to decide if more correction insulin is in order.

There is a low snooze too. That I have at 20 minutes. If I’ve had a low alarm, I sure as hell want to keep an eye on it. That said, I’m yet to see a low alarm.

No, my control hasn’t improved. No, with one exception a few months ago, I haven’t re-gained my ability to feel lows. I’m still flying blind. No, as you can see, I still eat like an idiot. I recently compared my relationship to sensible diet to being like a televangelist. I understand the word. I preach the word. I believe the word; but I’m still in the back room screwing the church secretary. I’m easily tempted by culinary delights that would leave me healthier if I could resist their charms.

Must be because I became T-1 late in life; after fully buying into the American diet. That’s my story and I’m sticking to it.

No, I’ve not seen a low alarm because the magic of predictive alarms really works. When I first read about the MedT predictive alarms I had a vision of a wrinkled gypsy crone with a brightly colored head scarf and large gold hoop earrings peering into a dusty and cracked crystal ball. (In reality I’m pretty sure that the guy who came up with this wears wire-rimmed glasses, a suit and tie, and spends waaaaaaay to much time at the office rather than out having fun.)

I was pretty skeptical that this hocus-pocus would work. I mean, I could see that in theory, in perfect world, in the laboratory, that it would work. But out with the Elephants, in the wild of America’s carb-soaked streets, in the complex bodies of T-1s….well, now that’s another story altogether.

But it really, really, really does work. No shit. Every time I get a predicted low alarm I do a fingerstick to discover that my BG is a bit lower than the Guardian thinks. No surprise given the lag between capillary glucose and interstitial fluid glucose. The alarm is looking for either an 85 at night or a 75 during the day, as those are the settings I’ve selected. It’s looking 15 minutes into the future, again, because that’s the time window I selected. In most cases when the predictive alarm goes off I’m actually already about 5 points below the low threshold. But who cares? Those number are still solidly above a hypo. I’ve had an accurate advanced warning that lets me take proactive action. A quick glance at the graph will confirm the rate and speed of the drop in progress. Hmmmm….D.I.P. Drop in progress=Dip. I like it. New word for the International Diabetes Dictionary!

Where was I? Oh yes. Now ParaPump had a graph too. But you had to (A) turn the damn thing on by pressing a couple of buttons and (B) you had to remember to look at it at all. It’s simple threshold alarms weren’t much help. By the time the alarm went off, you’re already going low. If you set your low threshold artificially high, you are plagued by false alarms.

I’m sure the design wizards at MedT think we’ve got diabetes on our brains all of the time, when in fact, we are all doing everything we can NOT to think about our diabetes. Diabetes can be all consuming, forcing out work, family, fun. I want to be healthy, but I don’t want to use all of my energy to do it.

The new Guardian is exactly what we need. It is a way for us NOT to have to think about our diabetes. It frees us because it watches out for us in the back-ground and alerts us to when we have to pay attention. Of course it still could alert us a bit more aggressively. Which brings me to my new Timex from Wal-Mart. It’s part of the Expedition series (see the Hemingwayesque self image above) and cost me less than 50 bucks. Burnished stainless steel. Kaki face. Leather band. Retro-future in an art deco kinda of way. A device out of a time when devices had both beauty and function as a requirement. It is waterproof to 50 meters and it’s alarm will wake the dead. The Guardian is only water resistant to a splash and I was recently told that’s why the alarm couldn’t be louder. Considering my new watch, I think some one is blowing smoke….

OK, enough ranting. Fact still is that I’ve had no lows or even real low alarms. I get the predicted alarm, which reminds me that I’m diabetic. I check my sugar and find it is already below 80. I look at the graph and see that sure enough, I’ve been steadily (or sometimes rapidly) dropping for some time. I open my go-bag and get out a cherry slice, eat it, and go on with whatever I was doing.

It’s never been easier to be diabetic. Even when your hunting elephants.

There’s no such thing as a free lunch

So we have a new family member. She has the most stunning blue eyes you’ve ever seen. She cries a bit, of course, but she’s still so little. Wonderful, silky hair. Long tail. Yes, we’ve been adopted by a cat.

So I’m not quite sure if I’m a great humanitarian or a cat-napper. I’ll tell you the story and you can all vote via comments: great guy or cat-stealing criminal.

The cat showed up a week or two ago at my mother-in-law’s house. Tiny little thing. Came to her door and “cried” until Mickey (short for Mariquita) broke down and fed her some scraps. Pretty soon the cat was around more hours of the day than not.

The cat also kept trying to get in. Mickey wasn’t going to stand for that. The cat almost tripped her too, as she was carrying out her trash, weaving between Mickey’s legs in that anaconda-like way skinny cats can do.

At first I didn’t give the cat too much thought, I didn’t know if it was a stray or a mooching visitor. That is I didn’t give it too much thought until Mick told me she’ fed the cat fideos and the cat went crazy for them and ate all the leftovers. Fideos, a local recipe, is spaghetti fried in a thin tomato sauce. Cats, to the best of my knowledge, don’t generally eat pasta. This, I realized, was one hungry cat. Out of the blue I decided I should take the cat home with me.

Then I remembered that I have a WIFE. Then Rio asked if he could have the cat. I gave him one of those, ‘probably not but we’ll see’ kind of answers. The next morning Deb came in and said, “I’ve been thinking about that cat…”

So off we went to PetSmart. I read that Pet spending last year topped 38 billion (yes, with a B). Now I know why.

Our mission: cat food, litter box, litter. Simple. Cheap.

PetSmart is bigger than your average grocery store, but smaller than a Wal-Mart. They have four aisles dedicated to Cats. Shopping for a Cat is like shopping for baby clothes. If you aren’t careful you can very easily spend all the money in your checking account. And like with babies and small children, the cat will most likely be more delighted with the box than what came in it.

So about 45 minutes into our ten minute errand at PetSmart I heard a funny noise. Beeeeeeep! Kinda like the noise a cell phone makes when the battery is dying. I checked my cell phone to find I had left it in the car again. Damn! Beeeeeeep! OK, so it can’t my cell phone, oh, wait a minute, it’s the new girl!

I slide the Guardian out of her plastic belt holster with a satisfying cliiithunk. The BG graph is missing. Instead it says “Low Predicted.” Ah hah! Magic in action.

I’m sure a few readers ears have perked up: did you say it beeped loud enough to be heard? Well, yes and no.

I’ve found that recently I’ve been sleeping right through the vibrations of my various devices, not waking up until the audio backup alarms kick in. Seems I’m more sensitive to waking up to noise right now. New Girl has more voice that ParaPump, but not by much. A far cry from the earth-shattering, every-one-in-the-room-turns-to-look alarms of the original Girl.

Side note: my contacts at MedT tell me the problem is in waterproofing. Keeping water out tends to keep sound in. While MedT products aren’t rated for scuba diving, they are designed to survive short accidental submersions. I’ve actually been accidentally submerged at least twice in my life; both while working as a photojournalist. The first time I didn’t lose any gear but damn near lost my life. In a split second I decided to forgo the guaranteed Pulitzer Prize winning photo, abandon my gear and dive into a flood to save another human being. Makes me a poor journalist but a pretty good person. I can live with that. The second time I went down with a full camera bag of Nikon bodies, lenses, flash, and police scanner. None of the above survived.

So my first thought was screw the waterproofing, give me a loud alarm. Then I thought about my encounters with water, and then I thought about my friend Erin, whose pager fell off her belt and got flushed down a toilet. On her first day on the job. Kid you not.

I’d be pretty pissed if my Guardian fell in a toilet and short circuited. Still, there’s some pretty smart folks at MedT. I’m betting there is a way to keep water out without keeping sound in. For starters they could make the device beep and vibrate at the same time. That would help.

So anyway, deep in PetSmart didn’t seem the place to test how accurate the predicted low alarm is. I calmly ate a cherry slice while contemplating cat nip toys and flea collars. Thus with early interdiction, the predicted low never came to pass. Not a bad thing.

It’s also worth mentioning that there was no panic-induced overeating to create a rebound hyper. Warning, Action, Smooth end of potential problem. A guy could get use to this.

So low averted, my free cat cost me $94.83. Mind you the cat hasn’t even come home with us yet. The break down went like this:
Food dispenser: $ 9.99
Water dispenser: $ 9.99
Cat food (dry): $ 9.99
Four cans wet cat food: $ 3.08
Litter Box, covered, with filter (but not the $149.99 self cleaning model): $ 15.99
Litter (poor first choice, but that’s a story for another day that I probably won’t ever tell): $ 3.99
Small toy with wire cage and bell: $ 1.99
Flea collar (just in-case): $ 7.99
Cat-nip stuffed teddy bear (guess who insisted on that?): $ 4.99
Scratchy pad: $ 3.99
Radio Controlled Mouse (if it keeps both Rio and the cat entertained it’s a bargain): $ 14.99
Tax: $ 6.85

Oh yeah, plus a $1 donation at the cash register to JAB…some sort of homeless pet outfit. Like who’s gonna say “No” to that????

We got home late at night and the cat was waiting. I had her in my mind as barley more that a kitten. She was quite shy at first, avoiding most human contact. Mickey had picked her up on a few occasions so she scooped her up and put her in the car. The poor cat rocketed all over the interior. Top of rear seat. Dash board. On top of my head. She’d probably never been in a car before. But we all made it home OK.

Twenty four hours later Kaki is sitting in my lap purring and grooming my arm hair with her tongue. We’ve all settled in amazing quickly. She’s actually not a kitten at all. Her fur is perfect. Shinny and smooth. Not what you’d expect from a stray. She’s long, maybe two feet nose to tail. She weighs nothing. You can feel her shoulders and ribs when you pet her. Shy at first, she is now very affectionate with the whole family.

I may be a cat-napper, but given her weight, if she wasn’t a stray she was at the very least neglected to the point of abuse. She’s now in a loving home with shelter, food, water, and even some much appreciated milk. I’m not feeling too much guilt.

My mother was surprised when I told her the story. “Aren’t Siamese cats very expensive?” she asked, “How did one come to be a stray?” Well, disregard for cats and dogs runs sooooooooo deep in Northern New Mexico I’ve twice seen veterinarians cry. No shit.

So more on my new family member. She’ll jump up on your lap or the couch, but thankfully shows no interest in counter tops, spending most of her time on the floor. Sleeps under one of our beds. (I was frantic the first morning when I could find no trace of her in the house when I got up). She’s very vocal. During the day, despite all the nice soft places to sleep she seems to prefer the magazine shelf of our mission-style coffee table.

And lucky for us all, she shows no interest in infusion set tubing, unlike the cat of one of my dearest pumping-blogging-cat-owning-friends.

Not free, but worth every penny. Sort of like Continuous Glucose Monitoring. Well, there’s no such thing as a free lunch.

Empowerment

One of my sisters, who has an agile, creative mind and a great sense of humor, once advocated the theory that the world was flat until Columbus sailed around it. “The weight of his ships caused the very edge to collapse and turn in on itself, making the world round,” she told me when I was young enough to almost believe it. Hard to prove otherwise, after all. No matter what you think of Columbus now, you have to give him credit for having the intellect to recognize the world was round (or could be made round with the weight of three small ships) and the courage to prove his point.

Worlds tend to stay flat until someone sails around them. Recently I’ve had reason to suspect that our flat diabetes world might actually be round too. I’m not sure I have the courage to sail around it to prove it, but I’ll at least raise the issue.

I first began to suspect the diabetes world isn’t flat just the other day, when I did a truly great thing. I gave a man we’ll call ‘Tom’ control of his life again. I gave him the tools that empowered him to gain control over his diabetes. And the experience has led my mind in a whole new direction.

We have a growing number of Type-1s at my clinic, mostly, I suspect, because I’m there. We T-1s are lone wolves by statistical happenstance rather than by choice, but we are social animals like anyone else. I saw a kid in Target last week wearing a MedT pump and I almost grabbed him and hugged him, I was so happy to see one of my own kind in the wild.

At the clinic I now have eight T-1’s so starting next month we’re going to add Type-1 group meetings. Pretty exciting, but of course the rest of my 200 patients are Type-2s.

Some will argue that the two conditions shouldn’t even have the same name, as they are soooooooo different in many fundamental ways. Any T-1 who has been accosted by some ignorant fool and accused of having brought diabetes on themselves by over-eating probably falls into this camp. When I worked at the largest hospital in the northern half of my state I even had a senior RN tell me that I “didn’t look like a diabetic.” I told her the big red ‘D’ that had been tattooed on my forehead when I was Dxed finally washed off.

Oh yeah, back to my point. I feel that all diabetics have more in common than we differ. We use many of the same meds. We share much of the same technology. We suffer the same complications, fears, challenges, and depression. We’re not quite the same family, but we are all certainly the same tribe.

But recently I’ve been thinking a lot about BGL testing. I read somewhere (and I wish I could remember where I read this) that there was a study comparing T-2 on orals who test vs. those who don’t and found no real difference in outcome. At the time I thought it was the stupidest thing I’d ever heard of. How can one control diabetes without checking your blood sugar, for Christsake?

When Tom’s Type-2 went to the next level he’d exhausted his oral options and it was time for the insulin talk. A brief side on treating Type-2 diabetes: First, on Dx, a patient is instructed to lose weight, eat sensibly, and exercise. This first step so universally fails that I’ve done away with it at our clinic. It’s too much change too quickly. Patients given these instructions can’t do it, then they don’t come back because they don’t want to face the negative wrath of their provider. Sort of like crawling under a rock to die, but usually justified with “but I don’t feel bad.”

Our approach, instead, is to medicate the patient to safety, ask them to give up only regular soda and to use Splenda in coffee and tea instead of sugar. I’ve had good luck with this approach. As sugars begin to drop and the patient starts to feel energy they’d forgotten they had, they are ready to make a series of small changes to their diet and activity. I call it “winning the war one tortilla and a time.”

Now, Type-2 medication plans look like a wedding cake. First you start with Metformin, at a small dose ‘cause the stomach needs time to tolerate it, then keeping racking it up until the patient is at goal or you’ve reached the max dose. When the first layer of the cake either fails or loses it’s effectiveness you add the next layer. So the second layer, if your doctor has been living with cavemen, is a sulfonylurea agent like Glipizide. Terrible stuff.

Picture this drug like the slave-driver with the whip in the back of the Roman galley. Row! Swishhhhhcccraccck! Row! Swishhhhhcccraccck! Row! Swishhhhhcccraccck! Row! Swishhhhhcccraccck! Row! Swishhhhhcccraccck! This drug makes the pancreas over-produce insulin 24-7 to try to overwhelm the inherent insulin resistance that is part of Type-2.

The problem is, well actually, the problems are as follows: you are producing extra insulin all the time. If your activity is up or you skip meals you are hypo prone. These hypos are harder to predict than the ones those of us shooting or pumping insulin have to deal with. For folks on insulin therapy, most hypos come from fast-acting insulin. You know the window of opportunity the hypo has based on when you bloused. Back to the Glipizide, the other problem is that overworking anything, be it machine or body part, has only one inevitable outcome. It will burnout. Then the patient is totally insulin dependent.

I’ve taken scores of people off this horrid drug. I have however, put one man on it. A A1C 15.7 commercial truck driver with morning fasting numbers in the high 400s and low 500s. Anyone else on the planet would have been learning to use a flexpen the day they came in to the clinic; but if I put this guy on liquid insulin he loses his license and his livelihood. After much soul searching with the medical director, we chose glip as a “lesser of evils.” The shit really does work. The guy is doing great. For now.

So as I say, we usually skip this layer of the cake and go straight to the TZD. Use to be we used Avandia until the recent flap. I can’t honestly tell you if Avandia is bad stuff or not. We pulled every one of our Avandia users off, migrating them to Actos, Byetta, or insulin. I don’t think much of the study that caused the trouble but I also didn’t think much of the Avandia rep sitting in my office and telling me with a straight face that his company, who made 3.2 billion-with-a-B dollars on this drug last year alone, wasn’t in it for the money. The real tragedy, he told me, wasn’t any money GSK might have lost, but was all these poor diabetics who might have to do without their meds. “We’re only in this to help the patients,” he said with the sincerity of the world’s best used car salesman.

I bit my tongue, told him that of course our door was always open to him but that Avandia didn’t have a place on our pharmacy shelves until the smoke cleared. Even if I was totally convinced that it was safe (and I’m not) I doubt that at this point I could get my patients to take it, even if I held a gun to their heads. As a side note, the mother of a Avandia rep in the mid-west told me her son’s bonus last year was $55,000. Yeah, not his pay, just his bonus. I don’t make that much working three jobs.

Once the met and the glip and the TZDs are maxed its time to talk about insulin or Byetta. (If the @#$%&# insurance companies would pay for it I’d start many people on Byetta the day they were Dxed. However, our world being what it is, a patient has to “fail to reach goal” for six months on all of these old school meds before insurance will even think about paying for something that will actually work.)

OK, so it wasn’t really that much of a “brief” side note after all. Maybe this is why I wasn’t able to get that job at Reader’s Digest. Aren’t all of you glad I’m posting weekly now instead of daily? Think how much more time I’ve freed up for all of you!

Back to “Tom.” As every day passed over the years Tom’s diabetes progressed. Like a glacier moving down a mountain slowly but relentlessly an inch per year his diabetes slowly but unstoppably became worse. During the same march of time his oral meds began to lose their effectiveness. His body adapted to them. They didn’t work as well as they once did. The entire wedding cake was maxed at each level. His morning fasting numbers were stuck at in the 150s. He checked diligently. Watched his diet like a hawk. Took his all his meds but was still powerless to stop the glacier. He was very frustrated.

I showed him a demo flex pen and discussed the ups and downs of insulin with him. He had no fear of needles, but had a problem. His hands have a Parkinson-like shake. He didn’t think he had the motor control to give himself a shot. His wife completely freaked out at the thought of having to give him shots. It was then my eye was caught by a very expensive paper weight on my desk. An Exubera inhaler.

When the novel inhaled insulin first hit the market about a year ago our clinic was actually the first non-endocrinology practice in our state to have both real inhalers and powered insulin packets. I like to keep us on the cutting edge and I like to have every possible tool to use.

Life being what it is, only the poor and the smokers were interested. We never scripted it out. I used it several times and liked it well enough. It has a very flat profile compared to liquid insulins, the excursion is blunted. I just wish they had thought to start with an inhaled basal insulin rather than a fast-acting. Most of my T-2s need basal first and once they are use to taking basal shots, inhaling the fast-acting doesn’t have that much appeal.

But now it looked like I had a good candidate. As a bonus, his real problem seemed to be his post parandials. I felt we had a good chance of bringing his morning fastings into line if we knocked down the post p’s.

So, long story short (hehehe) we got him set up. I called my Pfizer rep who came over for the “insulin start” bearing chicken-green-chili-alfredo-lasagna. Heaven on a plate. We trained Tom then he and I and one of my crew (I have a staff of five, four of whom are D-folk) all took “hits” on Exubera inhalers. Looks a bit like a bong, but it feels no different than breathing normal air.

Tom started at 120 mg/dl. He ate a piece of the lasagna about the size of his head. And bread. And salad. And diet Pepsi (tastes better than regular Pepsi which I always hated in my pre-diabetic days). We chatted and took regular finger sticks over the next three hours. He drifted gently down into the high eighties, then came back up to 106 and stayed there. His blood sugar never went higher than where it started. It never went too low. It acted just like a non-diabetic person’s blood sugar. Mine also drifted down initially. I was ecstatic to be able to watch my body’s response to the new insulin in real time on my new Guardian. About an hour into it I had a slow steady rise which peaked around 130 then settled in, a hair high in the 120s. It blew my mind. I’m still hooked up to the pump, but I’ve been experimenting with at least one meal each day using Exubera to see if it is more excursion-free than liquid insulins. I’ve become increasingly convinced that glycemic variability is a greater evil in terms of causing complications than average blood sugar (within limits) is.

Speaking of watching my blood sugar in real time, I gotta tell you, this is a real treat on the New Guardian. The original garage door opener just showed you a number and if my feeble memory serves me correctly, I had to press a button to get that info. ParaPump had a graphic display but it had it’s problems. You had to press some buttons to get there, and the screen timed out after a little while. ParaPump was also limited to three hour and 24 hour graphs. I found that the three hour’s vertical vs. horizontal displacement made all but the most severe drops look flat; and that the 24 hour was too much info in too little space. No way to make sense of it.

The New Guardian solves both of these problems very nicely. First, you can leave one of the graphs “on” all the time as a de-facto home screen. You do this by selecting “none” for Graph Timeout on the setup menu. She’s a bit of a battery hog when you do this, but the payoff is worth it in my book. I burn through a battery in a little over a week. My solution is to buy a huge brick of AAA bunny batteries at Sam’s Club.

The device has a battery strength icon in the upper right. My advice, if you are down to one little square at bed time, is to put in a fresh battery. Trust me on this one.

While I’m on the subject, next to the battery icon is the telemetry icon. It’s officially called the “Sensor Icon” and all it really tells you is that the machine is in communication with the transmitter. If your transmitter goes around the dark side of the moon, just like with NASA in the moon-shot days, you’ll lose telemetry and the monitor won’t receive data from the transmitter. Unlike the old Guardian, however, this data is not lost. The smart little seashell will hold about a half hour of data. I can now take my morning shower without worrying about losing data. Also on top of the screen is the current time. So the device doubles as a digital watch.

Off to the right of the graph, on the bottom right in nice large numbers is the most recent SG, or Sensor Glucose. This terminology is relatively new and serves to remind us that we really aren’t monitoring our Blood Sugar any more. SG is the new BG, as it were.

Above that is a graph type “headline,” 3 hour, 6 hour, 12 hour, or 24 hour. Above that is the time at which the last SG was measured. A quick glance at this number and the time at the top of the monitor tells you how soon you are in for an update.

Remember, continuous glucose monitoring is not continuous at all. It is every five minutes. The best analogy is motion picture film. Motion pictures don’t really move at all. You get the illusion of movement by projecting a series of still images at a very fast rate.

I have settled on 6 hour as my favorite graph, and I leave my New Girl on this graph pretty much 24-7. It puts in current glucose into a perspective that makes sense to me and the length and height of the graph really work. I can see the flow. The trend. The speed. All with very little brain work on my part. Columbus’ compass had nothing on this little beauty for navigating me safely through dangerous waters.

The 12-hour graph is pretty cool too, and I’ll often check it to see how the day has been shaping up. I almost never use the 3 hour or 24 hour graphs.

For the Exubera lunch I slipped the girl out of her belt case and set her on the edge of my desk were I could watch her out of the corner of my eye. I never lost signal and she worked like a champ the entire time.

When Tom left, three-and-a-half hours after he arrived, carrying his giant “starter kit” box with an inhaler, spare chamber, insulin powder packets, spare release units, carrying case and a sheet of stickers to put on his calendar to remind him of chamber maintenance requirements, he had the biggest smile on his face I’ve even seen. He told me he hadn’t seen BGLs this low in years. He felt great, and he felt empowered. He told me of his frustration of taking his blood sugar and seeing numbers he knew where bad and not being able to do anything about it. Now he knew he could take a 1mg packet as a correction bolus if his sugar was too high. Now he knew he could vary the amount of insulin he took depending on the size of his meal. He understood that his life just got more complicated, but that it was worth it. Now he was in the driver’s seat, not his diabetes.

As a side note, all of us left that day with by far the coolest drug rep pens any of us have ever seen. Thin, sexy, burnished silver reminiscent of stainless steel. It has both an ink pen and a stylus for PDA or tablet computer. At the top it has two buttons. One turns on a bright clean blue-white LED flashlight. The other a laser pointer. Very, very, very cool.

The next day Tom came to our monthly diabetes support and education group, his laser-flashlight-stylus Buck Rogers pen in his pocket. He stood up and told the group of 31 diabetics that even though it had only been a little over 24 hours that his life had been changed forever and for the better. It was the best thing that had happened to him since he had been Dxed. It was so great that he could now do something about the numbers he saw on his meter.

These words echoed in my head as I drove the 75 miles from mountain valley the clinic is nestled in, to the open mesa lands where I live. That night, on the back porch, smoking my pipe and unwinding from the day by watching thunderstorms sweep over the distant landscape I talked to Debbie about it. She’s a borderline pre-D/T-2; and by far my most non-compliant patient.

“I hate, hate, hate, hate, HATE taking my blood sugar!” she told me. “If it is a bad number what can I do? It just depresses me and then all I want to do is eat chocolate.”

Hmmmmmmmm…..now I’m thinking about the study of diabetics who test and those who don’t again. Exactly why do we ask D-folk on oral meds to test? It’s convenient for me. I can look at their sugars when they come in and see if adjustments are in order. But I could do that with A1C’s too. We’ve got an A1C machine in the lab, I get results in six minutes. We’re getting a second machine later this year, so we’ll have one in my office too. But if I do want a clearer picture of fasting vs. post p wouldn’t it be just as useful for me to have the patient test intensively for one week before his/her visit rather than all the time?

On rare occasions some patients will make connections between what they eat and what they see on their meter. Most times patients come in and say “you’re not going to be happy with my numbers;” or “I’m pretty happy with my numbers.” Actually most times they tell me “I forgot my meter and log book.” But either way, those on orals have no power to change what they see. So much for the self-managed disease.

So I’m beginning to question how we use BGL meters. I wonder if it is a good idea to have oral med patients checking every day. This last week we participated in a University of New Mexico RIOS Net project. RIOS stands for Research In Outpatient Settings. They run field-based mini clinical studies. This one focused on A.N. as a risk factor for diabetes. I chatted with the state coordinator about setting up a study at our clinic. If we can get grant funds we can set up several groups using various testing strategies to see what works best. I do have one fear deep in my belly. I’d hate like hell to give insurance companies any ammo for not covering test strips, but ultimately what is best for the patient is best for the patient. If testing less makes life easier and does not change the quality of control then that is what we should do.

But that is in the future, for now we stick with “test, don’t guess.” For now we hand out BGL meters like candy at Halloween. For now we continue to supply the means of seeing blood sugar without the tools to correct it. For now nothing changes.

But now I’m starting to question if the world is really flat after all.

The new girl in town

So I’m having this mid-life crisis. Being a good, patriotic American I knew there was only one solution: I needed a sports car and an expensive young mistress.

But there were three problems with the sports car. One: it couldn’t make it up my half-mile dirt-and-rock driveway that is, to say the least, in poor repair. Our road is so bad that the Jehovah Witnesses don’t even visit and the FedEx guy hates me. The Second problem: I don’t have any money. And the third problem: I don’t have any money.

So without the sports car and the money I don’t really have anything to attract an expensive young mistress either. Graying, broke, middle aged guys just aren’t in fashion right now. Well at least I’m not losing my hair. And come to think of it, I already have an expensive mistress in the form of diabetes, anyway. Although, she’s not as fun as the other kind of mistress would be.

Actually, I always encourage my patients to embrace diabetes for what it really is: an interesting and time consuming hobby. It really is. It gobbles up all your time and money, is mostly frustrating, but highly rewarding when all goes right. It also involves all kinds of technology and math, so I guess it might be a better hobby for guys than for female folk, but….

So just when I’d given up hope on the mistress front, a new girl arrived in town. A California girl at that. (Regular readers can begin to guess where this is going and are starting to salivate.) Yes, today I got two medium sized boxes from our friends at Medtronic.

The first was the familiar cooler box. It’s like one of those trick presents some fool gives you for your birthday. It is a box, in a box, in a box. The huge carton has a very thick styrofoam sarcophagus inside it. The foam must be four inches thick. In the center is a cavity just big enough for the pharos’s heart. Too small for the entire king, sorry. But inside that is another box, flanked by still frozen gel packs. Inside that box is yet another, with a treasure fit for a king, or at least as expensive. A four-pack of CGM sensors. Nice!

The other box was about the same size, and full of many wonderful things. (Apologies to Lord Carnarvon and Howard Carter). There were IV3000 dressings, Unisolve Wipes—the very best a man can get—and IV prep. There was a Paradigm Link BG meter with the com cable. Then there was another box. Lime green with an androgynous mountain climber. Maybe a man, maybe a woman. Long hair, sunglasses and an interesting little box on his/her belt. There are also two pics of women. One eating, one sleeping. The box says Guardian REAL-Time Continuous Glucose Monitoring System.

Honestly, I for one, look forward to the day MedT gives one of their devices a two syllable name. Like I-Pod. Razor, Windows, Drano, Pop Tarts. See? You don’t need an entire sentence to convey the message.

I have a new name for this product in mind (collective cringe in California), but more on that later. I open the box and find….Manuals. A thin quick-start guide and a spiral bound users manual. This was a bit of a surprise, I’d heard on the grape vine that the new Guardian had some sort of cool, interactive, online training.

Below the manuals are four sheets of cardboard and then the whole enchilada. Packed snugly in perfectly cut out cubby holes in black foam are all kinds of cool stuff. There is one of MedT’s wonderful little sea-shell transmitters. Small, smart, and re-chargeable. No doubt the cause of countless sleepless nights at DexCom HQ and over at Abbott. There is a belt clip and a clothing clip. A Senserter device I can use as a paper weight. A test plug, and even two AAA batteries. One for the transmitter’s charger, and the other for the main event. I love it when you get batteries with your toys. In the basement of the box is a ComLink device with cables and software.

Oh yeah. Then there is the Guardian (I’m such a tease, sorry). Looks like a MedT pump. No-nonsense ash grey with a green ACT button. Green. The color that signifies full speed ahead. The color of life. The color of lights on a nuclear reactor that say everything is working perfectly. Hmmmm….also the color of money for MedT shareholders.

I’m so excited I could faint.

So I want to share some highlights of new Guardian features from the manuals to wet your appetite (I’ll report in detail on each as I try them out). Four, count ‘em, four different CGM graphs. Three hour and 24 hour like ParaPump; but also six hour and 12 hour to boot. And, answered prayers, you can leave the screen on to anyone of them. That’s right. She doesn’t time out and switch back to a blank screen. That means you can look at your waist and see you Sensor Glucose without pressing any buttons! Hooray!

Ok, so who is the person at MedT that we should all send chocolate and flowers to?

Other mind numbing stuff: you can set different alarm thresholds for different times of the day. What an awesome feature! I, for one, plan to set tighter control limits during the day and slightly more lax ones at night so I can sleep without be harassed by alerts that are not life threatening; while still being a control freak during working hours when responding to alerts is no big deal.

Huh. You can also check your average BG. Now all meters do that, but the number is worthless. It is only the average of when you check. But this would be the average of all the time…. It should even be possible to reverse engineer the math and get a presumptive A1C score. Hmmmmm….that’ll be a fun science experiment three months from now.

Other great stuff: user selectable rate of change alarms. Both up and down. And of course we still have the original threshold alarms.

But I saved the best for last. The most amazing feature. This new Guardian is said to be able to predict the future. No shit. I read it in the manual. This new girl has Predictive Alarms. I know. It sounds crazy. Even scary. Scazy! (Memo to Webster: a new word for you. If we can add “ginourmous” to the official lexicon of the English language, why not “scazy?”)

Anyway, according to the manual I can program how much advance warning I want. Say I choose 20 minutes, the machine will tell me twenty minutes before a low that it is coming.

Will it work? We’ll see. The science is sound. The device can track rate of change, knows your target, throw in a fancy algorithim or two and Presto! Still, it seems more like magic than science. But Clarke always said that a sufficiently developed technology was indistinguishable from magic.

If a couple of years ago someone suggested we’d have a device that could predict hypos we’d have laughed in their face. And then asked to be on the waiting list.

So, my less than two sylible name for the GRTCGMS is: Orcle.

Now the question is, will the orcle give us a clear and true prediction of the futre, or will she give us double talk and mumbo jumbo. Stay tuned, we’ll find out together.

Oh. Wait a minute. Orcle is taken by some itty-bitty computer company, isn’t it? Well that leaves us with Sybil or Pythia, neither or which commands instant name recognition.

Well how about Seeer? Crystal Ball? Tarot? Care to vote or contribute better ideas via comments? You know the drill!