CGM—the graduate course

The battered folding chairs are arranged in a circle in the church basement. One by one, the men and women in the room stand, introduce them selves, and then confess to their shared weakness. Then, all too suddenly, it is my turn. I stand and look at my feet while I gather my courage. I lift my head and look each person briefly in the eye, and then I say it:

Hello, my name is Wil, and I’m an information addict.

Yes, it’s true. I love to know everything about anything. Journalistic habit. So more of a occupational hazard, you understand, rather than a personality defect. Just want to make it clear I’m not a snoop, I just like to be well informed.

And the thing I most love to be well informed about is my diabetes, particularly the moment-to-moment status of my blood sugar. Thank God for Guardian.

At any moment of the day I can slip her out of her sturdy belt case with a satisfying KaClick, glance an my diabetes cockpit’s instrument panel, know everything I need to know, and return her to my belt with an equally satisfying KaThunk.

And should I have my head up my ass and not be paying attention when I should be, she’ll give me a head’s up. Assuming I can hear her. Well, it’s not a perfect world.

Since I’ve started CGM, back when dinosaurs ruled the earth, I’ve had a couple of times when finances forced me to be CGM free. It was miserable. With this newer Guardian it would be inconvincibly awful.

Despite the above mentioned VOLUME problems (I’m going to keep harping on this until Medtronic HEARS the problem and FIXES it… and I’ll be really pissed off if they don’t send me the very first ear-shattering upgrade…); this new Guardian is so far above and beyond my original that I’m convinced that withdrawal would be fatal. And given my new-found quest for tight control and my hypo unawareness, it could quite literally be fatal to be without it.

Being pump-free has had an unexpected consequence for me. I’m starting to explore features of this new Guardian that I had not paid attention to before. Overall, it is an amazingly well thought-out device. As always, however, I do have a few nits to pick.

The first set of features I want to tell you about is the “Capture Event” menu. It’s as easy to get to as anything on a MedT product (read that any way you want to). Press ACT once from just about anywhere, down arrow once and ACT again. Here you can choose to enter a variety of information into Guardian’s memory. Choose between, Enter BG, Insulin Marker, Meal Marker, Exercise Marker, and Other.

OK, so why on earth would you want to? Because if you enter this data Guardian will link it up with the real-time sensor data when it chats with CareLink. That puts an awful lot of interesting information in one place for you. When I was on the pump, it was impossible and un-necessary. Or so I thought. But now when I sit down on Sunday morning with my coffee for my weekly “post game” I have some pretty powerful info at my finger tips. All I need is CareLink and my food log to see how my therapy is doing and what adjustments might be in order.

Oh yeah, you should go get a cup of coffee too. This is likely to be a long post.

So I’ve discovered you don’t even need to take your Guardian off your belt to download her to CareLink. Just drop the ComLink into your lap, get some distance from your computer and let her rip.

As a side note, you can print a “Device Settings” report that shows how you’ve personalized the unit. Handy to keep a printout incase you get stuck by lightning or whatever and lose your settings.

First things first. The Enter BG screen lets you enter a fingerstick into the system that IS NOT a calibration stick. This is a great feature, and one of the things on my wish list back when I was bitching about the original crappy Solutions software. Everyone stand and applaud MedT for having the courage to include this. Why? You can now print out a report that shows, among other things, the difference between SG trace and random fingersticks. Anyone who reads this column knows that there are a number of times when a CGM unit will not agree with a BG fingerstick. Most times they are pretty close or trending in the same direction. Still, it is kinda cool to see it. I think most folks will be surprised at how good the system really is.

That said, while were are all standing, we should now “Boo” MedT for wimping out at the last second. On printed reports BG fingersticks are huge black squares that take up about 25 points of space on the graph. The intent, obviously, is to make BGs that are a bit off look more like they are close to the SG plot line. Sigh. You guys were sooooooo close to doing the right thing. Just give us a dot. Have faith. You have a good product. OK, everyone together now: “Booooooooooooooooooooooooo!”

You could also use this menu to calibrate if you want to, rather than entering a calibration stick into the sensor menu. I haven’t yet fooled around with the BD Paradigm BG meter that comes with Guardian. I had assumed that any finger stick would go to calibrate the sensor, a huge defect in the ParaPump system that beyond a shadow of a doubt is the cause of countless calibration problems and subsequently the wide spread belief that the sensor system doesn’t work very well. Now that I see you can opt out of using a BG capture for a calibration, at least on this menu, I’m wondering if the BD meter can be used and let you choose. I’ll have to fool around with it and let you know.

Next up, the insulin marker. Now here is a classic case of hiring a programmer who is not a diabetic and has never worn the device. When you open the menu you are given the choice of entering Fast Acting, Short Acting (even I’m not clear on the difference between those two), Intermediate Acting, Long Acting, Mixed 70/30, or Mixed 50/50. Looks like we got all the bases covered there. Now, when I enter, say my Levemir basal shot of 20u in the evening I go to Long Acting, dial up 20 units. Guardian then asks me if I’d like to store that dose. Delighted at a time saving step the next time around (as basal shots are almost always the same dose every time) I tell her “yes.”

A bit later I take a hit of fast acting. When I open the screen it has defaulted to 20 units. I dial in my 3 unit hit and save. Later, back at the Long Acting screen my 20 units is gone and replaced by 3 units. That’s right. Even though the menu has six types of insulin, the Guardian has only one memory. That’s (insert favorite expletive) nuts. As basal’s are almost always the same, the device should be able to remember a different number for long-versus-fast insulin. Likewise, the meal menu has Breakfast, Lunch, Dinner, and Snack. Again, some D-folk ways have the same size breakfasts or snacks; but Guardian will only remember the most recent meal, regardless of meal type selected. Groan. This pisses me off more and more each night when I have to scroll up to 20 to enter my basal shot. Also worth mentioning, the insulin units are in tenths. Only pumpers get tenths. The rest of us deal in either whole or half units. Somewhere on the preferences menus we should be able to select moving by full units.

So why bother? Why not just enter 2 units of basal and forget about it? Because CareLink can provide us with some handy stats if I give it the right information. Both the “Quick View Summary” and the “Trends Summary” give insulin stats including average daily totals and breakdowns of the percentages of fast vs. long, an important bench mark for determining if you ratios are set right. Generally speaking about half of your total daily insulin should be basal and half fast. If your percentages are way the hell off, odds are you are using one type of insulin to do the job of another type; like taking corrections of fast-acting to compensate for inadequate basal.

Quick View is a 14-day report that shows you the general trend of your glucose. It uses a set of vertical blue bars hovering over each day. The bar shows the peak and low of the day, and a white circle somewhere along the bar shows the day’s average. Little black hash marks on the left of each bar show fingersticks. It is supposed to be a way to quickly see trends. To me it just looks like the thingy that Doctor McCoy had above the beds of the sickbay on Enterprise on the original Star Trek. Not having McCoy’s advanced education I can’t make much sense out of either one. Damn it, Jim, I’m a Un-certified Diabetes Educator, not a Doctor. Quick View also has an Insulin Injection Log, in the form of a table. The bottom of each column is white, showing basal. The top dark for the fast acting. Height of the column lets you compare one day’s insulin to the next. I prefer the Trends Summary, which has much of the same information plus some other useful features.

Trends is also 14 days, and also has a slightly smaller version of Dr. McCoy’s bio-function monitor, but without the BG hash marks. That’s the top panel of four. Next is our Insulin Injection Log, and below that a graph of the Carb intake for the day. At the bottom is a table that summaries key data like average glucose, carb and insulin totals etc. But what is really cool about this report is that the data line up. You can scan your eye up and down the page to see the relationship between glucose, insulin, and carbs. You can scan your eyes left to right to left again and see the relations ship of the data from day to day. On the right side are some min-summary tables that average glucose for the period, average insulin use by total and type for the period, and average, max, and min daily carbs. A nice snap shot.

A cousin to this report is the Modal Day BG report. Don’t run this one. It only tracks fingersticks. Why would you want to look at data based on 3-6 fingersticks when you can look at data based on 288 readings? Into the shredder with that puppy.

Now the really pretty report is the Sensor Daily Overlay. As you might guess from the title, it takes the sensor “trace” from seven days (or fewer if you want) and lays them on top of each other. Each day is a different color, so the chart is quite lively. There is also a dotted line that shows the average of all seven days. I love looking at this chart, it is one of the most visual. It is soooooo cool to look at the swerving, snaky, river-like lines that show the travels of our blood sugar throughout the day. The value here is that if you see all your lines are jumping or dipping around the same time each day, you know you have some adjustments to make.

The Overlay also includes stats on Excursions, which emerging research seems to indicate may be the biggest villain in terms of diabetes complications. That’s the one bummer about being on CGM; you’ll realize that your world is more full of storm-tossed seas than you ever imagined in your worst nightmares.

I love the Daily Summary report, but I’m frustrated by it at the same time. There are three graphic frames. The top one shows glucose and has the SG trace for the day with the BIG black boxes we talked about earlier showing finger sticks. It also has a little horn that shows alarms, but doesn’t show which kind of alarm. High? Rate of change? Sorry, they all look the same. Middle block is insulin injections and the bottom is carbs and exercise (which I’m allergic to). With a food log on your knee this report could really help you fine tune your carb counting and blousing. My gripe here is that it takes foreeeeever to generate reports in CareLink. You can look at one day, but to go to the next takes forever. Want to go back. Oooops! You need to create it again.

I’d love to have CareLink on my hard drive, rather than Online. I’m not sure why this isn’t an option. It may be a monster program that would eat up too much space. Maybe no one thought of it. Maybe they are secretly mining our data. To print out all the days would devastate a small forest. Maybe they cold create a flip feature that would allow you to load a weeks’ worth and flip back and forth on screen (hint, hint, hint…if you folks are reading).

OK, I saved the best and most innovative for last. This report is so innovate I didn’t “get it” at first. This graphic chart pulls sensor data out of time and associates it with a meal bolus. You need to set some preferences at CareLink as to the time ranges in which you eat breakfast, lunch or dinner. But it seems, from looking at my first chart of this kind, that the software then “moves” sensor overlays to show the effect of time-after-eating on the trace post-meal; rather than clock time. To be clear: other reports lay out sensor data based on the clock built into the device. This report associates data to a count-down timer that starts when you eat. It is the difference in using a stop watch or a clock for timing a relay race.

Take breakfast, for example. The chart starts at one hour before, then shows the meal, then up to four hours after the meal.

What’s intriguing about this is that, separated from the flow of clock-time, you can really see the effect of various meals on your SG. I was surprised to see that on the three days that I remembered to enter meals in the Guardian (hey, I was just starting off with this feature) that the breakfast curves were nearly identical. I hadn’t noticed that on the Sensor Overlay, as the meal times were a bit off.

CareLink is not Co-Pilot (the Abbott meter and pump software by which all others must be judged) but it’s not too shabby and used right can be hugely helpful in interpreting results. After all, paying attention in real time is only half the usefulness of CGM. The other half is all that information you can study and use to adjust your therapy; to understand cause and effect in ways impossible when just taking fingersticks, unless you took 288 per day.

I’m quite confident that if they gave all us D-folk CGM units and a half-day off (with pay) per week there would be no looming health care crisis from our tribe.

Well, my poor little fingers are cramping. I’m gonna take the weekend off. I’ll see you all on Monday.

Oh, yeah. And if you made it all the way through this post; you need to join me in the church basement next meeting. You’re an information addict too.

The envelope(s)

I use to like checking the mail. The lab was a mail-order operation for decades. The mail use to be the source of our income. People sent us money (and film and negatives) everyday. The mail was the source of all blessings.

Things have changed.

I opened the lab’s “big box” at the branch Post Office. A moth flew out. No shit. It really happened. Then I opened the small box, where we get our personal mail.

Bill, bill, bill, junk mail, second notice, termination notice…

Oh God, an envelope from my health insurance company. What has the world come to when we get cold chills down our spines when we get missives from our insurers?

Riiiiiiiiiiiiiiiiip!

Let’s see here….Si necesita una version de este documento en espanaol…..wtf? I flip it over, but the back is blank. It is common in New Mexico to find Spanish on one side of a letter and English on the other. I flip the letter back over and scan further.

Ah, there is English further down.

Dear Wil, thank you for choosing Presbyterian as your health plan. This is how dear John letters usually start. This letter is to notify you that Dr. E has requested durable medical equipment on your behalf. We want to notify you that this has been approved. The approval is for: Purchase of 3 boxes of sensors…

Hooray! Pres is gonna buy one-half of three more boxes!

If you’re out of the loop, I got approved for one box earlier. I’m running low so our first salvo was to have Medtronic ask Pres to either re-approve or extend the approval. I know that it is still hit and miss, but I’m really starting to feel like I’m going to be covered long-term. Too bad it’s only at 50%; but if I was still with Blue Cross I’d probably still be 100% uncovered (and not in a sexy way, either).

So maybe envelopes aren’t always bad news afterall.

Next envelope is from Rio’s school.

Riiiiiiiiiiiiiiiiip!

Dear Parent(s): we would like to meet with you to discuss your child’s academic performance to date……

Diabetes Heaven

As diabetes is practically a religion anyway (we have rituals, rites of passage, arcane knowledge, and lots, and lots, and lots, and lots, and lots of prayer); I think we deserve our own special afterlife.

I submit we deserve Diabetic Valhalla.

Now for those of you who didn’t know, Viking heaven was called Valhalla. As I recall it involved fighting all day and at the end of each day Valkyries resurrected the day’s dead and everyone went back to the great hall for feasting and orgies. Next day it happened all over again and so on. Well, the nights sound pretty good. I’m not too sure about all the blood, dismemberment, and dying during the day….I think we D-folk have had enough of that in this world; we don’t need any more in the afterlife.

So I’m picturing Diabetic Valhalla like this: we’ll feast on carbs all day and sleep hypo-free at night. Our bodies will be healthy and complication free without so much as a pimple.

Once a month we’ll gather at a bonfire and cast our meters, pumps, syringes, lancets, and log books into it. And the Valkyries will resurrect our stuff so we can burn it again next month.

What’d ya think?

Your insurance cares about you

No really. It’s true. At least that’s what the girl on the phone said. She works for Life Masters. She’s calling to tell me (on my cell, and using up my minutes) that Presbyterian Health plan cares so much about my health as a diabetic that they’ve hired Life Masters to provide me with totally free health advice on the phone.

You know what I told her?

I told her that if Pres really gave a shit about my health they wouldn’t cap me at 100 test strips per month, which only allows me to test three times per day on most days. I told her that, as I’m sure her records show, I’m a Type-1 Diabetic on two kinds of insulin. I should be testing at an absolute minimum of eight times per day to stay healthy; and more times if I feel the need.

If Pres really cared about my health they’d give me the tools that would allow me to take care of myself; instead of spending the money on phone advice.

Now you are probably wondering why I care, three strips per day is what it takes to keep my CGM calibrated. So what’s the problem?

The problem is that CGM, while it has come a loooooooooooong way, isn’t perfect yet. You’d be a fool to put it totally in the driver’s seat. You still need finger sticks for therapy adjustments. How many per day? Depends on how good your control is and how hypo prone you are. Don’t forget that the better your control (which keeps you out of the dialysis center in the long run) the thinner the ice under your feet. D-folk with really good control have more hypos. People with really good control need more strips to maintain that control in safety. CGM is an indispensable tool for me, but I’m not ready to kick my test strips to the curb just yet.

More on test strips. They cost $1 each at retail. There are no generic alternatives. There are no patient assistance programs (well, one company will give you a coupon for 20% off if you are really poor). So that works out to…. eighty cents per strip, times four per day, times 365 days in a year… more than a thousand bucks. That’s well more than most really poor people could afford, even if it were their only out-of-pocket cost for diabetes.

Test strips are universally under-provided by insurance companies, especially for anyone on insulin. The big insurers take a page from Medicare who will only cover ONE STRIP PER DAY for folks on oral meds (including hypo-prone agents like Glipizide) and only THREE STRIPS PER DAY for folks on insulin. I’ve got CGM and I can’t control my diabetes on three strips per day.

Hypocrite alert: yeah, I know I questioned the utility of test strips for patients on orals a while back, but my over-flowing email inbox has convinced me that most patients on orals benefit from testing.

All of this proves that your health insurance really cares about you…. so long as you are one of their shareholders.

Me and my pen

I’m a walking billboard for Lilly Pharmaceuticals. Don’t you think they should pay me? Or at least give me free insulin until the cure?



Yep, I’m really liking my new pen. And the juice in it. More on the juice in a minute. Let’s focus on the delivery device first. A while back I reported that I was being driven crazy by the necessity of spinning the dial 360 and pulling out the base to set the dose. Sometime after that, I realized that there is a raised section on both the barrel and the dial. You can do the spin-and-pull in the dark, at the bottom of a 300 foot coal mine, at midnight, during a lunar eclipse. Although, hopefully you’ll never need to.

I find that I’m pulling the cap, unsheathing the needle, and doing the spin-pull thing in auto pilot while I’m making up my mind about how much insulin to take. Reader’s Digest Version: it’s no big deal in the end. I’m totally use to it and it doesn’t bug me or slow me down in the least.

The pen is much smoother in its action than it’s Novo counterpart. Delivery is smooth and fast.

I’m partial to things monochrome from years of B&W photography and lab work, so I really like the look of the pen. White barrel, grey cap. Clear insulin chamber and a clear plunger. Even when the pen is almost empty it looks good. Both the Novo and Lilly pens won’t let you dial more than what’s left in the pen. Nice safety feature, that.

As to the juice, the Humalog is working better for me, in my body, for the moment. I don’t think for a minute that it is a superior insulin to Novolog. I used Novo for years and had good results from it until recently. Maybe my body just adapted to it or something. Who knows. I’m glad we have more than one to choose from.

How better: my excursions are lower and end faster. That’s worth the (insert favorite expleivie) $55 co-pay to me. Even though I could get the other stuff for free. Damn. But, let’s face it, the most important investment a D-folk can make is in an insulin that really works for him or her. Right?

Stupidity Curve

Dateline—Denver, Colorado
3:05 a.m.

The insistent alarm finally woke me up. It was the backup alarm that sounds vaguely like a European police siren. If you hear it you know that Guardian has been trying to wake you up for more than 15 minutes.

It’s slightly louder and longer than the normal alarm, but not much. We’re in the guest suite at my Mom’s high-rise. Deb and Rio are sleeping soundly in the other bed, five feet away. None of the alarms have stirred them either. By comparison my sixty-dollar Timex Expedition watch can wake everyone in a 2.3 mile radius.

When the Europe cops arrive you don’t know if you are high or low. Highs, lows, and monitor status alarms all have their own personality. It’s one of the things I really like about the Guardian family of products, but they share the same last-ditch backup.

Blearily brained I search around for the source of the noise and silence it by feel, Guardian’s buttons are raised.

I force one eye open and look at the dash board. It’s a high SG alarm; quite the surprise ‘cause when I went to bed I had been worried about a hospitalization-grade hypo.

We’d spent all day helping my mom with her kitchen. Installing spice racks, cleaning cabinets, getting reading for painting. So the day stared with an early Starbucks run, included a Home Depot run, and extraordinarily well bloused lunch at Noodles, and finally a drive up and over to Boulder for a Chinese dinner with that branch of the family.

Chinese is always bad for me. I took half the pen of Humalog (not really) after we ordered to get ahead start. Then the food came. I had never been to a chinchy Chinese restaurant before. The plates were petite. I began to have serious worries about the amount of insulin I had taken. Lacking much real food I resorted to filling up on rice and must have over done it.

By the time I got back to Denver that evening I was at 314 with two up arrows. By the way, Green Tea Ice Cream is very yummy.

I took a correction and started a violent ride downwards. Exhausted I went to bed very early and fell asleep when my head hit the pillow.

Now, in the dark, I’m studying the bizarre graph by it’s glowing backlight. The crest is 358 shortly after 9pm. By 11 o’clock I’m down to 140. Good stuff that Humalog. Shortly after that I bottom out at 138. Then a slow climb begins. I’m now at 284.

What the Fu…? Then I recognize the curve. I’m going to start calling it the Stupidity Curve. It is the graphic representation of my body poisoning itself because I, once again, have forgotten my Levemir shot. I groan. Find my glasses using the Guardian’s back light as a flashlight, and get out of bed. I stumble to the bathroom, and squinting, I turn on an overhead light and rootle around in my toiletry bag for the dark blue Flexpen. I’m thinking it would be nice to have a user-programmable daily alarm or two in this Guardian. (Hindsight Editor’s note: it does, but they don’t work very well, more on that in a future post.) After all, you wear it 24-7, it might as well do more than monitor your blood sugar. My retired CoZmo pump had no end of alarms you could set. When I first stated Lipitor I had an alarm to remind me to take it. Right now I need a Levemir alarm. While I’m at it, an on-board carb data base would be nice, and a list of all the Starbucks locations in the United States.

I take the 20 units of Levemir on my right side and then take a couple of units of Humalog on the left and then collapse back into bed.

In the morning the bell curve of stupidity and smooth correction is nicely displayed on my 12-hour screen.

So starts another day.

Thieves like us

Date line—Pueblo Colorado
Shortly after dark

We idled slowly up the street, using only our parking lights, creeping along inches from the curb. Rio distracted with Sponge Bob on portable DVD; his mother and I prepared to commit a crime.

We paused midway between the Hampton Inn and the MicroTel Inn & Suites. I scrunched down in my seat, hiding behind our tinted windows, no light but the dim glow of the lap-top balanced on my knee.

Yep. We’re trying to steal internet to upload a post to my blog.

I hack in to the Hampton’s wireless network with a reckless criminal glee. So this is what it is like to be an anarchist! I kinda like it.

“We’re in!” I whisper.

“In what?” asks Rio

“NOTHING,” simultaneous from both parents.

Ahhh, but the Hampton has outsmarted me, while their network is unsecured, they’ve got me firewalled. “Damn,” I say, “they want the code from our room key.”

I could try a couple of random numbers and letters, but it is unlikely I’d get lucky. I’m sure real hackers would not be stymied so easily.

I review the other wireless networks in range and connect to the MicoTel network. My homepage fills the screen. Success! I log on to blogger and go straight to my dashboard and upload.

Done!

As I slam my lap top shut, two construction worker-types with open bottles of Corona beer pull up and get out of their van. We exchange guilty glances. Everyone is breaking the law tonight.

I stash my laptop behind my seat, turn on the headlights and make our get-a-way, speeding off into the night wild night, lightning dancing across the horizon. A thief in the night, the highwayman of the internet.

A little larceny is good for the heart now and again.

The Taco Bell White-Knuckle Badge of Courage Award

Our good friends at Lilly Pharmaceutical have published a comprehensive Nutrition in the Fast Lane pamphlet. It gives you all the horrifying Super-size Me un-nutrition data from a long list of fast food joints. It’s an honest-to-God Webster’s carb-fest.

As Debbie has a Taco Bell craving, I now have the opportunity to put the data to the test. We are in Colorado City, about 20 minutes down the interstate from Pueblo, the likely location of a great many Taco Bells.

I don’t know quite what I’m going to order, but all the food at Taco Bell tastes the same to me. Doesn’t matter if you wrap it in a flour tortilla, stuff it into a corn-shell, fry it up, serve it rolled, flat, or in a bowl. The stuff all tastes the same to me.

Bottom line, it won’t really matter what I order. I decide on a Burrito Supreme and two crunchy tacos. 70 carbs. With this size of meal I decide that a 30 minute pre-bolus will be in order.

After a quick conference with Deb, we decide to go for it. I shoot up with seven units from my grey & white pen. Adding to the risk, I had, 15 minutes before, taken a couple of units to knock down the excursion from a bottle of Godiva we picked up at a Gas station in northern New Mexico.

As we zip up the interstate I have a down arrow on the Guardian.

Ut oh.

On the south side of town we find a Taco Bell. Rio wants to eat outside, but it is getting dark. There is a stiff wind and it looks like rain. He’s overruled. We go inside and order. Before I can fill my diet soda, gather up hot sauce packets and napkins, our order is ready.

None too soon. I’ve got two down arrows.

I scarf down a taco, then eat the burrito. After polishing off the second taco, Guardian has me at 140 and dropping like a stone. I do a fingerstick on an Abbott Precision X-tra meter. 75. Oh crap.

Drink some real soda, suggests Jezebel.

Now, I know that eventually the food will soak up the insulin. If I wait long enough, and if I don’t pass out, it’ll all work out just fine.

I cross the Rubicon. No fast acting carbs. I don’t want the excursion. I commit myself to wasting several more test strips. Guardian still has me dropping, but she’s still playing catch up to the fast moving hypo. That doesn’t necessarily mean that I’m still really still dropping. But in this case I am. Now I’m at 69. The family is still eating. I play with a straw to try to take my mind off the blood sugar. I tear the tip of the wrapper off and slide the paper down the straw about an inch. I quickly bring the straw to my mouth and with a quick puff send the paper missile flying at Rio. It strikes him square in the nose. “Hey!” shouts Rio. Bull’s eye! It’s one of our favorite games. His mother hates it, mainly ‘cause his aim is sometimes off and he’s shot untold numbers of waiters and guests at neighboring tables. Most people are pretty good sports about it.

My patience being worn down by fear, I check again. Now 72. Maybe a rise. Maybe the same, it’s well within the tolerable 20% error allowed for “accurate” test strips. But not dropping. Guardian is now at 80 and still showing a drop.

We make small talk, but I’m not really engaged. Finally, Guardian stops around 76 and begins to level out. Finger stick shows 79. Looks like I’m in the clear.

Scary stuff, but it worked out perfectly in the end. The meal peaked at 159 around two hours out, and settled down nicely. The combination of “nutrition” data (using the world lightly), a good carb-to-insulin ratio, and white knuckle courage, won the day.

I love eating out with hard carb data. It’s good to know what to bolus for. Makes eating out less work. And isn’t that what eating out is supposed to be about? You don’t need to cook, serve, or clean up. Eating out is much less work for “normal” folks. For us D-folk, it’s a hell of a lot more work.

I think there should be a Federal Law requiring all restaurants to publish calories, fat, carbs, and fiber on their menus.

Then eating out could be a treat for all.

FrickingFedEx

OK, so my empty pocket book has had no effect on my generous heart. And those ruthless bastards over at Smithsonian took advantage of that fact when they sent me their catalog to tease me. In it I saw the most beautiful shawl of the style Deb likes to wear; in a color that would coordinate perfectly with her turquoise jewelry.

As we are headed up to Denver to help my Mom out with some stuff it seemed like the perfect “good wife” gift. No occasion at all mind you. Just an unexpected present.

The timing would be tight, so I ponied up for the overnight shipping at great cost. That was on a Saturday. I figured they wouldn’t ship until Monday. Tuesday night came and no shawl. I checked the order status online and found it was “processing.” I fired off an angry email and next day heard back. It shipped Tuesday, not Monday. It’d have it Wednesday when I got home from the Clinic.

It wasn’t there.

I fired off more angry emails demanding the tracking number, and, exhausted, went to bed.

I got up six hours later to get Rio dressed and off to Kindergarten. We head to Denver after we pick him up this afternoon. I call the 24-hour customer service number and try to be polite, even though my blood is boiling.

They show FedEx delivered it yesterday, at 4:10 in the afternoon; which of course, they didn’t. I ask for the tracking number and go to FedEx’s web site myself. I pull up the signature. It has the name of one of the front desk girls at the clinic. You gotta be kidding me.

I load Rio up and head into town, on the way in I call my early-bird assistant on my cell. Hey this is a dumb question, but did FedEx deliver a personal package to me at the clinic yesterday? Yep, she replies waaaaaaaaay to cheerfully, I found it this morning and I put it in your office.

(Insert favorite expletive, in bold, underlined, add italics).

Shocked silence then “Ummmmm…..I think your breaking up, I didn’t quite make that out,” she said, embarrassed.

So I drop Rio off, drive 156 miles out of my way, on a day I’m going to drive across two states to get the damn shawl. It is exceedingly beautiful.

Only in a state like New Mexico would a FedEx driver drop a package addressed to a person at a certain business in one city at another location, in another town altogether. It’s like a thousand-square mile small town.

What really aggravated me even more was the fact that if someone had mentioned it to me yesterday, I could have just taken it home last night. The package and I were within 100 yards of each other for over two hours.

When I finally got home Deb was still asleep. I took the shawl out of its package, draped it over her and went into the library to start writing this post. Shortly there after my soft clicking (not) on the lap top’s key board—bad habits left over from the days of manual typewriters—woke her up.

Is that you?

Yeah.

Didn’t you get some sleep?

I went into the bed room. No I just got back from the clinic.

The Clinic?! Why did you have to go over there?

I sat on the edge of the bed, “to get this.” And I flipped the corner of the shawl up over her face.

Delighted gasp.

So, inspired by my young patient yesterday, I took a correction bolus in my arm today. Too early to tell if it worked. Would be handy to take some shots in the arm; like when out eating. I’ve got pretty scrawny arms, if I take an IM hit instead of a SubQ the insulin will go into fast-forward and it could end badly. That said, I’m using a Novo 31 gauge 6mm pen needle, so it’s pretty short.

My arm aches, but probably only ‘cause I’m paying attention to it. I’ll let you know. Now off to get the punk and head north. I’ve got a brick in my car incase I see a FedEx truck.

An elegant injection

It was our first Type-1 group meeting at the clinic. We had a smallish turnout. Four T-1s, one family member. Still, having that many of our tribe in one room at one time in this part of the world is probably some sort of record. The conversation was lively and we all had a blast.

At one point the call went out: Let’s all check our blood sugars!

I fetched a meter and a hand full of disposable lancets.

Around we went. An 86 from a 30-year-old male, a 93 from the family member, a 176 from a young T-1 mother of the two most beautiful little blonde haired, blue eyed girls you’ve even seen (the oldest of whom was sitting on my lap--Rio has a complete crush on her because he thinks she looks like Tinkerbelle), a 133 from my assistant who swears she’s not even a little bit diabetic, and 368 from a 16-year-old-girl Type-1, and finally a 163 from me.

My teen-age patient whipped out a Novo Flexpen and in one fluid movement uncapped it injected one-handed into her upper arm and returned the pen mysteriously to where ever it was she kept it.

My jaw dropped. It was like ballet-meets-magic. I’d never seen a more graceful, smooth, effortless injection.

She noticed I was staring at her, speechless.

“What?” she asked, defensively.

“That was beautiful,” I told her.

The shape of stupidity

You gotta be fucking kidding me. My BG is 358? How can that be? It’s still dark, my alarm set to go off in five more minutes. It is my routine morning calibration check, I haven’t even looked at the girl yet.

I run my hands under my sheet until I find the box. Pressing the two outside buttons at the same time lights up my 6 hour screen with a blue-green glow. The SG plot looks like a glacier cut valley, soft and round like a very flat “u.”

The peak on the left side, at bed time, was the result of two many pieces of Deb’s famous home made pizza. Crust from scratch. Alfredo sauce. Bits of soft tender streak, vine ripe organic tomatoes, bell pepper and red onion. Baby swiss and mozzarella cheese, just barely turning brown. Oh my God…

I took 11 units of Humalog for an estimated 110 carbs. It wasn’t nearly enough. At bed time I took 6 more units as I topped 400 and my Guardian cheerfully advised me that my SG was “above 400.”

OK.

Fine.

My stupid fault.

But why the mystery nocturnal rise? The correction got me down into the 180s. I stayed there for hours and then started to climb. Way too many hours later to be the second-stage surge in carbs from the fat-delay of pizza.

Nagging thought……did I? Could I? Surely I didn’t?

Did I forget to take my basal shot of Levemir at bed time?

I clearly remember taking the correction. But the daily shot…. Hard to remember if you remembered to do something you do all the time. Or are supposed to do all the time. Takes 30 days to develop a habit, good or bad. This is day four on shots.

If I did forget, my between meal numbers today will be bad. But if I take a half shot now, and I DID take my shot last night It’ll be hypo city today. Better to run high and safe for one day.

But this is for sure, I damn well won’t forget tonight.

B-days are Bad days

I know that today my blood sugar will be suboptimal, even if I still had the pump. And I haven’t even gotten out of bed yet. You see, today is the all-staff meeting and celebration of September B-Days.

It’ll be a sugar fest.

Turns out that there are an unusually large number of folks born in September working at the clinic. “I had no idea I was surrounded by Virgos,” muttered E as we headed to the car after work last week, “but this explains a lot.”

Yeah, I’m one of the Virgos, I doubt anyone will be surprised by that. And before you ask, a pair of fours this year.

I check my blood sugar with a fingerstick, enter it into the Guardian, then swing my feet to the floor. The carpet is cold on my bare toes. Autumn is coming and the nights are getting cold. I get an alarm. Cal Error which stands for Calibration Error. The signal strength is too low to match up with the BGL I just entered. Damn. The pathetic thing is, the Guardian was with in a few points of the fingerstick. I try again and get another cal error, followed by a "replace sensor" message. Damn. I’ve had really, really, really bad luck on this sensor lot. The first one out of the box…. Well, I was taking my underwear off to jump in the shower and somehow the band caught the IV3000 and I pulled the transmitter and the sensor out in one fell swoop. Made me sick to my stomach. I guess I’m not the type of guy who could ever light a cigar with a 100 dollar bill. It served less than a day and was pretty far off the entire time. Double damn.

The next one ran erratic for the first half of it’s life and now this. I sigh and get another sensor out of the fridge, turn on my coffee pot, take my Synthroid, and jump into the shower. The smell of brewing Rift Valley blend fills the house.

Skin still soft from the shower to the point I’m dripping on the kitchen floor, I open the shrink wrap and take the clearpurpleishgrey sensor from the bag. I slip cover off the insertion needle and pull the front adhesive off. I pinch up some flesh on my left leg and rest the needle on my skin. I slowly push the needle through the skin and a wave of pain cascades across my leg. Fuck! I snap the needle back out of my leg. Damn, musta hit a nerve. I move over a few inches and try again, but now my skin is hyper sensitive. The needle isn’t even in a 16th of an inch and the pain is too great to continue. I try twice more in different locations. No go. Now four small holes are oozing blood.

I switch to the right leg. I rest the needle on the skin, gather up my courage and ram in the needle up to the hilt in one steady un-stoppable motion. It’s in.

I whip the back adhesive off and suddenly a new wave of pain, the worst yet, sweeps over me. Hastily, I pull out the inserter needle, leaving only the sensor behind. The pain fades to a dull throb. Not my morning. Usually these things don’t hurt at all.

Major pain until the needle comes out is the sure sign of a crooked sensor. We’ll see what happens. Pumpless, new therapy, and now headed off for a 12.5 hour day unsure how the sensor will work…. On cake day at that. Some days it just doesn’t pay to get out of bed.

To add insult to cake, my Pfizer rep shows up at the clinic mid-morning with a Starbucks traveling jug and boxes of goodies for all. The excursion starts out like the Alps, rounds off, and turns into a perfect bell curve. The combination of Humalog and expert carb counting wins the day.

Oh yeah. I think I forgot to mention I switched to Humalog from Novolog yesterday. I haven’t been all that happy with the response I’ve been getting to the Novo, even though I’ve used it both in shots and later in the pumps since the beginning of my diabetic career.

That said, the Novolog just isn’t working well for me anymore. Excursions followed by crashes. I was having this problem pumping too, the last couple of months. Despite the universal free availably of Novolog I decided to try one of the few sample pens of Humalog I’ve been able to get my hands on. Too early to tell, but it preformed like a champ today.

The Lilly disposable pen for Humalog is more elegant looking than Novo’s Flexpen. It has a white barrel with a grey cap large enough to carry the disconnected but still re-usable disposable pen needle in. Nice. Slightly larger in diameter than the flex pen, but small enough to be convenient and discrete to carry. Somehow is has a higher quality esthetic to it that’s hard to put my finger on. Flexpens look a bit like low-end highlighter pens. The Lilly pens look more like a fine fountain pen. Also nice is a little built in magnifying glass that makes the dosing numbers larger for those whose eyes aren’t getting younger.

While also not a Swiss Watch, the movement is noticeably smoother than Novo’s pen. On the down side, however, is the madding necessity of an extra operational step. You must first spin the dial 360 degrees, pull the base away from the body of the pen and then dial in your selected dose. Drives me crazy and I’ve only taken a handful of shots with it.

Anyway, as I bounce up my unimproved and declining drive way at the end of the day, I’m quite smug that I rode out two kinds of cake and Starbucks goodies with only a relatively short term excursion that was landed promptly with no hypos and only one correction.

I put the Accord in park and toot the horn Navajo-fashion to let the family know I’m home. The door flies open as I get out of the car and stretch my weary body. The sun is going down and I left before it crested the mesa to the east. “Daddy’s home! Daddy’s home!” as Rio dashes out onto the porch the smell of Debbie’s homemade pizza crust drifts out the door from the kitchen and I know that no amount of clever carb counting or high tech insulin will save me from the end of the day excursion that lays ahead of me.

MDI day two—with Guardian to Guide me

You often don’t realize how good, or bad, you have it until your situation changes.

I never realized what a fricken hassle the pump was until now. I had just adjusted to it. Last night a 4 a.m. leg cramp woke me from a deep sleep. My mind still 50% in REM, I was able to rip the covers off and spring out of bed to get some weight on the leg as my calf turned to granite.

I did this without yanking out an infusion set.

This morning I was able to get up and shave without something dangling from me. And in the shower I now had only one place to be careful not to scrub too hard, rather than two. I’m liking this un-tethered life.

Also, the new Guardian transmitter has better range, plus a memory that stores your SG data for a half hour or so if you do lose telemetry. Bottom line: you’re not married to it the way you are to a pump.

Second night of Levemir report: hit the sack at 158. Woke up at 87. Little scary, but if the ice is thick it’ll be fine. I cleared a NovoLog pen needle with one unit. Such a small little droplet one unit of insulin is. My breakfast is only 10 carbs. Will this little drop really do the job? Will it let me down and send me high? Will it crack the ice under the Levemir and send me low?

We play with one-tenth units on pumps with nary a thought, but to actually look at a unit of insulin…. Such power in such a small space.

So long as I can get good control, I think I’m going to like this new and simpler life. With Guardian to Guide me, I’m optimistic.

New world order

Well, my new life has started off with two positive experiences, and one of them involved putting on my pants. More on that in a minute.

On the fourth day of my last infusion set I picked up a Levemir Flexpen and a NovoLog Flexpen. And a box of pen needles. At 6pm I set a temporary basal rate of 0.0 units per hour for ten hours. The plan was to take the basal shot at 10pm. Suspending the basal drip four hours up stream would ensure all the old juice was out of my system before the new stuff started.

I was nervous. I’ve started, I dunno, probably close to 100 folks on Levemir, including poor T-1s like myself who can’t afford pumps. But it’s different when you are starting yourself. On top of that I’d never personally used Levemir at all. In my pre-pump days Levemir did not exist yet. I used NPH at night, but that seems too stone age and I’ve seen what a good job the “green juice” does.

I took a mid-evening correction on the pump, and then in its last gasp of service I pumped dinner. The plan when awry when too much after dinner exercise (sword fight with the little one) triggered a mild hypo followed by the inevitable rebound hyper. When 11pm rolled around I was around 200.

I uncapped the Levemir pen, pulled the paper backing off of a pen needle and threaded it on to the pen. I pulled the outer cover off and threw it to Kaki to play with. I carefully removed the needle sheath and dialed in a two unit dry shot to get the air out of the system. Nada. One unit more and a clear drop of life-saving miracle fluid appeared at the tip of the needle. Time to go back to my roots.

My most recent pump basal was seventeen point something units per day. I increased that by 20 percent and rounded off for a starting Levemir basal of 20 units per day. I’ve moved a couple of people from shots to pumps, but never the other way around. I assumed if I did all the math backwards it would work out OK.

I pinched up a little skin, slid the needle in and pushed in the “plunger” at the dial end of the pen. 20 units is a long push. The disposable Flexpen, while a wonderful device, does not exactly have the movement of a Swiss Watch. It was slow and sort of…. grinding? Well, that’s not quite right, but you get the idea. I relaxed my pinch, rested the nose of the pen against my skin for a count of ten and slipped the needle back out of me and re-sheathed it. Very un-eventful. Of course I take lots of “shots” of saline and the like demoing pens for new inductees into our club, so it’s not like I haven’t taken a shot for years and years.

By the time I hit the hay my BGL was at 220, but I was in no mood to add a correction bolus to a new insulin.

Then, I slept. And I didn’t die in my sleep. OK, so three positive experiences. When I woke up, the first thing I did was dig around in my sheets and comforter to find the Guardian. The six hour graph looked like the heart monitor on an ICU patient who has gone on to the next world. Absolutely flat. Amazing. I scrolled up to the 12 hour graph, to see that the bedtime 220 leveled down to 200 within an hour of my head hitting the pillow and for the next 8 hours my SG (Sensor Glucose, the new BG) drifted gently between 188 and 212. Quite amazing. I know from looking at BG logs of our many Levemir users that it has a pretty flat profile; but most of that crowd are T-2s and you never really know what’s happening between finger sticks. This is the first time I’d seen a continuous graph of Levemir. Gotta say, I’m pretty impressed.

Now wait-a-cotton-pickin-minute some of you are saying. You were at 200 all night long and you are happy? Are you fricken nuts? Well, I might be fricken nuts, but that has nothing to do with the conversation at hand. This was a fabulous performance. Basal insulin’s job is to keep the boat on a steady keel. It’s not the fault of the green juice that it went in to the game high. If I had gone to bed at 120 SG I have every reason to assume I’d wake up the same.

Now, of course, it has not even been 24 hours yet. I can’t say what the afternoon has in store. Much to early to tell if the 20 unit hit is really the right amount or not. But I’m not scared anymore. I’m ready for this new challenge life has thrown me. But I’m sure glad I’ve got Guardian-Girl along for the ride though.

After reviewing the night’s lack of action on the Guardian’s screen I broke out the orange juice. Not that kind. NovoLog pens have an orange label and cap and Levemir pens have a green (some say teal) label and cap; thus orange juice and green juice. The pens are otherwise identical. The colors are supposed to make sure you don’t take the wrong stuff at the wrong time. Hasn’t stopped some of my patients from nearly killing themselves. Local celebrity CDE Virginia Valentine likes to tell her patients to link the color orange to eating an orange. Use the orange insulin when you eat. That’s pretty good. After one of my MDI (Multiple Daily Injection) Type-2s got confused and took 60 units of NovoLog instead of the Levemir I’ve been telling people that orange is DANGER and that any time you have an orange pen in your hand you need to think about what you are doing.

Where was I? See? I go off on so many tangents that even I get lost. Oh yeah. So I broke out the OJ to take a correction first thing in the morning before breakfast. Gotta keep your head in the game a lot more with pen syringes. You can’t just glace at an insulin on board screen or double check you last bolus.

Actually, the folks at Lilly just introduced an insulin pen with a memory. And it does have the action of a Swiss Watch. I could easily write myself a script for it and have my boss sign off, but there are a few problems. It is a bit bulky (not as bad as the old OmniClick from Lantus) and it takes Lilly HumaLog cartridges. I’ve never used HumaLog, and I have to reason to suspect there is anything wrong with it. My problem is different. The good folks at Novo literally flood our state with samples. I know a lot of Docs so I can always mooch a Flexpen. Confession time: in my entire career as a diabetic I’ve only actually paid for insulin one time. Paid for plenty of other stuff to support my diabetes, but I’ve been really lucky with the insulin. So I can (most likely) use Flexpens for free or pay whatever my co-pay would be for the Lilly cartridges.

So I un-capped an orange pen and got out a calculator. 200 current SG minus target of 125 equals 75 divided by my best guess average correction factor of 35 points per unit equals 2.1428571 which of course I average to a two unit hit to start my day. One challenge I’ll need to face is that when I’m in a rush I often drink a Slim-Fast Low Carb Diet shake. They have less than 5 carbs which, as you probably have forgotten, you then bolus as 5 carbs. Of course, that’s half a unit of insulin, which is a problem. Again, Lilly has a beautifully crafted half-unit pen with the same problem noted above. Novo makes a Junior pen that delivers half units too, but they never seem to sample them. Maybe I need to make friends with a couple of Pedio Endos.

All things being equal though, this could have started off much worse and I’m feeling more up-beat than I expected to.

So that’s about it for today. What? My pants? Oh yes, an unexpected pleasure was that this morning, for the first time in years, I was able to pull up my jeans and tuck in my shirt like a normal person. No getting tangled up in my infusion set hose. No pump falling off the belt.

It was so fast.

So easy.

So alien.

Chop sticks, tooth picks, fiddle sticks: goodbye pump, hello pens

My fall from upper-middle class to medical poverty is nearly complete. I dropped my life insurance and I’m switching my aging cars from full coverage to the minimum mandated by state law. On the bright side I’ll be saving $700 by switching to Gieco. Of course, it’s mainly the coverage change, not so much the carrier. But what the hell, I wanted to give the little green guy a plug.

When looking at my dwindling income and rising outgo (gas, electric, and propane just keep going up and I can’t fucking believe how much a quarter basket of groceries costs now a days), I realized that I could no longer afford to be diabetic.

So I decided that as much as I love all of you, I was going to leave the club. But then I remembered a key point. Like the Mob, you only leave this club dead. Well, that doesn’t sound like too good a plan.

My new health insurance has turned out to be less than a bargain. One of the things our the clinic’s insurance “expert” neglected to tell me is that our policy has a special “DM rider.” All diabetic stuff is only covered 50%.

The insurance did pay for one box of CGM sensors. Well, half of one box of sensors. We now have to start the battle all over again for the next box. But now I find out they’ll only pay for half of my infusion sets supplies too. It never ends, literally. We’re still doing battle over some of the final medical bills from Deb’s grandmother. Leaving the club doesn’t make your medical bills go away. Like some kind of genetic plague they are simply handed down to the next generation.

Oh yes, back to the story.

I’m running low on infusion sets. I now realize that I can’t afford both CGM and pumping if I’m paying half. After some miserable soul searching I’ve decided to try to go back to old fashioned “shots” and keep the CGM.

I’m a little apprehensive. No, I’m actually scared shitless. I’m seeing in person what James S. Hirsch reportedly wrote about in his book Cheating Destiny (it’s on my nightstand, but I’ve been too depressed to read it). We are becoming a nation of two new types of diabetics, not separated by disease process, but by economics. The rich will have the best technology, meds, and treatments. The rest of us will die early and miserable.

Kaki update and books you should read

OK, for all of you cat lovers out there, I have an update.

Don’t worry about the flea collar that I (in apparent ignorance) bought. The girl doesn’t have fleas. Yes, of course we’ll have her fixed. Once we are sure she’s not come to us in a family way. You know what I mean.

At first I thought she was a mellow cat. Hah! Not the case. She was just so starved that she didn’t have any energy. She is now acting like a proper cat.

She likes to sit on top of the fish tank and terrorize the angel fish. She can get from one end of the house to the other without ever touching a paw to carpet. She, in fact, can dash at about five-point-eight times the speed of light.

She is determined to eat my infusion set hose. Great cat toy, those hoses. Anyway, very soon that will not be a problem, but more on that sad story in the near future.

And, as befits her kind, she is now a certified huntress with one grasshopper and one small grey field mouse to her credit.

Every morning I find she has chosen to sleep in a different location. One day she jumped out from behind a 15 volume complete works of Jules Vern in our library. One day she was curled up in Rio’s booster seat. One day in a pile of laundry that didn’t get into the machine as planned the night before. One day on top of the coffee table, another time guarding over Debbie and Rio as they slept.

She’s rowdy, independent, inquisitive, and surprisingly affectionate; especially with the little one who frequently picks her up in ways that makes it hard to maintain cat dignity and dumps her into my lap with the happy exclamation of “Cat Delivery!” In short: she’s a cat. And my life is more interesting, and fuller, since she came to live with us.

On a completely different subject Rio brought home some plague from Kindergarten that my immune system had never encountered before and I spent the better part of a week and a half in bed with no energy to do anything but read.

So I highly recommend War Reporting for Cowards by Chris Ayers, Iron Coffins by Herbert Albert Werner, and Lives per Gallon by Terry Tamminen.

Cowards is about a London Times Hollywood correspondent who finds himself “embedded” with the US forces during the most recent invasion of Iraq. I don’t want to spoil the book, so just trust me that this is worth a read.

Coffins is an older book that was actually loaned to me by one of my patients. It is written by one of the few U-Boat commanders who actually fought for most of the war and survived. Losses in the German U-Boat arm in World War II were nothing short of appalling. It is supposed to be a book about the U-Boat war, but it is so much more. I was taken with his observations of how much things changed for him back home after every patrol as the war drug on and Germany’s fates became worse with every passing day. A sad book, but worth a read.

I’m currently a bout a third of the way through Lives. It was billed as a book about the true cost of our addiction to oil. I had expected an revealing look at all the sleazy things those nasty oil companies are doing overseas. I wasn’t disappointed by that, but the book had many other surprises too. Among tid bits to either keep you up at night or raise your blood pressure: as you are gassing up at three bucks more or less per gallon with the full knowledge that the oil companies are posting record profits keep in mind that these same companies are the beneficiaries of mind-boggling large government subsidies. Tamminen puts the total of these various incentives at trillion dollars per year. We even give the bastards tax payer money because the world’s supply of oil is dwindling. Can you fucking believe that? Tamminen estimates if we didn’t give the most profitable off all American corporations subsidies, tax breaks and other incentives we could give the very best health care in the world to our citizens plus build 1,500 new schools in every state.

More shocking than all of that, to me, is the fact that gasoline is a poison. Both as pollution, or just sitting there evaporating out of your fuel lines in the parking lot on a hot day. Of the many evils that make up the toxic soup of gas is Benzene, which has been linked to endocrine disorders. More and more of this stuff is turning up in our environment. What the author doesn’t know, but you and I do, is that Type-1 in adults is on the rise.

Benzene is on the rise.

Benzene can fuck up the endocrine system.

T-1 Diabetes is on the rise, surprisingly, in adults.

Hmmmmmmmmmmmm……

Titanic

I was the only one in our party that downed. Better odds than I’d expected, actually.

We’d come to Denver to take in the traveling exhibit of Titanic artifacts that have been raised from their watery grave in the deep, cold, dark Atlantic. It is a wonderful, eerie, amazing experience. You can run your finger across a chunk of the Titanic’s hull, touching history. You see clothes, money, a pipe and tobacco pouch. All preserved by the icy depths. There are chunks of the ship: a bridge telegraph that signaled the engine room to reverse the engines as the ice berg loomed. A compass. Rivets. A wall sconce. Part of the grand stair case. You walk down a reconstructed corridor on the First Class B deck and you find yourself walking back into history. You can gaze at a pair of eye glasses, one lens missing, and realize that they were most likely on a passenger’s face when he went into the water.

Book a trip to Denver. You won’t regret it.

There were many wonderful things about the exhibit. For the kids the show has created a huge block of ice, an ice berg of sorts, that they can touch. There are profiles and stories. Never too much to read, unless you have a five-year-old in tow. There is a huge chunk of the hull. There are massively enlarged photos. Bottles of champagne, still full, ready to drink by popping the cork.

Book a trip to Denver. You won’t regret it.

But one of the most interesting elements was the boarding pass. As you enter the exhibit you are given a boarding pass with the name of a real passenger on the ship. I was Mr. Richard Henry Rouse, age 50. A 3rd Class passenger who had lost his job as a coal miner during the coal strike. I was off to Cleveland, Ohio, where a daughter lives. My plan is to find work and then send for the wife and other daughter. Rio was Mr. Edward Ryan, age 24. He boarded at the Queenstown stop-over. The rest of us at Southampton. Mr. Ryan is also a 3rd Class passenger immigrating to Troy, New York. Debbie was Mrs. Elizabeth Hocking, age 54, a 2nd Class passenger from Cornwall. She is seen off by the YMCA choir which came to sing as her train left the station. My mother was 18-year-old 3rd Class passenger Mrs. Sam Aks of London. She is traveling with her 10-month-old son to join her husband in Norfolk, Virginia who had established a tailor shop.

In today’s dollars, we in 3rd Class paid about $650 for passage. The bottom-basement 1st Class ticket was $48,000. More than my house cost. The best suite on the ship would have set you back more than $78,000 in today’s dollars and you still would have had to pay extra to use the swimming pool.

Knowing what I did about the history of the Titanic, it didn’t look good for the home team.

Due to the nature of the artifacts; food, even bottled water, is forbidden in the exhibit. No ER sugar for me. I wasn’t even carrying a glucometer. I’ve actually become somewhat lazy about that. Guardian is just so damn reliable. I was stable, in the 140’s with modest IOB. I didn’t worry too much about hitting a glucose berg and sinking into the icy hypo depths.

At the end of the exhibit, spanning an entire wall, is a list of those who survived and those who were lost. It is broken into 1st, 2nd, and 3rd class, and crew. The crew took horrible losses. As did third class. That said, many third class passengers did survive; and many first class (mainly men) died.

This really tied you to the exhibit in a unique and powerful way. As people gathered at the board eagerly searching for their names there were cries of “on man…I downed.” Or, “I lived! I lived!”

As expected, I downed. To my surprise and pleasure, however, Rio survived. As did Deb; no surprise as she was a second class lady. My mother, however, must have had one of the most harrowing experiences of any passenger who lived. The 18-year-old mother was walking in a daze near the boat deck when someone snatched her baby from her arms to put him in a life boat. God apparently on her side, she ends up in a different life-boat, but they spend the night separated from each other and uncertain of each other’s fate. They are reunited on the Carpathia the next day.

Book a trip to Denver. You won’t regret it.

All the news that’s fit to read

So I’m having a wonderful evening. It is cool tonight so I’ve fired up the porch heater. I’m smoking my pipe, sipping water, and gazing out into the inky darkness. It is pitch black tonight, I can’t tell the horizon from the sky. The only lights as far as the eye can see are the little string that run across one side of my back deck; plus the dim glow of soft light coming through the sliding glass doors into the kitchen.

The only sounds are crickets and the distant ruckus of Deb trying to give Rio a bath. I’m relaxing and getting my mind ready for the day ahead when I recall that I forgot to read my AP News summaries on Yahoo this morning.

I debate with myself. The calm evening… or keeping in touch with the world… when I realize I can have my cake and eat it too! I nip inside to fetch my laptop. I surf wirelessly while I chill out mentally, basking under the warmth of the propane fire.

I click on links that catch my fancy, read more, then return to the main page. Then something disturbing catches my eye. The headline is “Some companies penalize for health risks.”

I click through from the summary to the main article. My blood pressure begins to rise as I scan the article. Apparently many companies are now starting to charge more for company health insurance if employees have health risks.

We need no further proof that the basic human right of health care is only given to those that won’t use it. Bastards.

It seems that many companies are now tying the cost of your employee health insurance to your BMI (Body Mass Index), or your blood pressure, or your cholesterol.

Huh.

So the same SOBs who won’t cover weight loss drugs to help overweight people get healthy now charge more for being fat? That makes sense in a perverted kinda of modern American way, doesn’t it?

To add insult to injury, many in healthcare (including me) regard BMI as bogus. It does not take into account either frame type or muscle mass. Probably some poor weight lifter out there somewhere will have to pay more for his health insurance ‘cause his BMI is not “good enough.”

Luckily, no hint yet of the chill that went down my spine. So if they can get away with charging a premium for weight or BP, how long until they start singling out people with chronic conditions?

I guess it is a darker night than I realized.

Evolution or revolution?

Apologies to all of you creationism nuts…err….folks; but evolution is a beautiful thing. My new girl is amazing compared to my cave-man original guardian.

Remember those illustrations in out-dated physical anthropology textbooks that show the progression of evolution over millennia? First comes a monkey type critter, then walking in front of him is an ape, who follows a hunched over human with a brutish looking forehead, who is following a naked Mel Gibson carrying a spear?

I’m envisioning a new poster for Continuous Glucose Monitoring. First comes the original MedT “Gold” system. It was hard-wired. You wore the monitor on your belt and connected it to the sensor by a cable. It was your silent partner for three days. You had no idea what your numbers where. The box stored them and you took it back to your doc for a download and printout at the end of the study. It was quasi-continuous (like all CGMs, none are really “continuous”); but not real time.

Next would come my beloved wireless garage-door opener Guardian, then the ParaPump, and then, at the top of the evolutionary ladder, the handsome Adonis of CGM: the Guardian Real-Time. I’m drooling on my keyboard thinking about what the nextGen Guardian on MedT’s drawing boards must look like. Ahhhhhh, to be a fly on the wall of a certain lab in California…..

Back to our evolution poster. We should plug the GlucoWatch in on the poster somewhere, an evolutionary dead end like Neanderthals. Other cousins on the family tree would include the DexCom branch: the original, then the one you could download, now the one you can wear seven days. Each of these tinny evolutionary steps requiring a fossil expert to tell the subtle differences between the models.

We should also include Abbott’s Mythical Navigator. Kind of like Sasquatch, we keep hearing reports of it, but there seems to be no scientific evidence that it exists. For years Abbott’s web site as had different images of the device. It seems to be evolving without living in the market environment.

With two major exceptions my new Guardian completely fulfills and even exceeds my wish list that I drew up after using the original for six months or so.

The most important thing that I wanted and got: a visual graph ‘cause I’m a visual guy. The original Girl gave me a number every five minutes. It’s been a while, but as I recall I had to press a button to get even that limited information. In some ways, this was really just a fast BG meter, and I bet a lot of folks just used it with that mind-set. To many, it was just a self-monitoring BG meter with some back-up alarms for when the shit hit the fan. Treating a CGM this way is a bit like using a microwave oven to just boil water, and cheats the user out of the real power of CGM. That said, the design of the device made it a lot of work to get the most out of it. That’s not true anymore.

Now I can just slip the new Girl out of her clever plastic holster (another improvement) and pressing no buttons whatsoever, I can take in my blood sugar environment with a glance. I want to stress my choice of words here. I didn’t say I could check my blood sugar with a glance, I said I could take in my entire blood sugar environment. Let me digress about this a bit.

Accuracy without context is worthless. I recently enjoyed a DVD of a movie called A Knight’s Tale. It is a harmless medieval tale of a commoner who poses as a noble to participate in jousts. The opening scene rocks, literally. Set to the tune of Queen’s hit rock song We Will Rock You we are treated to a marvelous re-interpretation of a jousting match. The scene is accurate in appearance and costume, but the crowds do the “wave,” have their faces painted to match the colors of their favorite nobles, dance, and otherwise act pretty much like modern Americans do at the Super Bowl. In an instant, I got it. I really understood the flavor of the joust in a context that made sense to me. All the sudden I could understand the past through the filter of my own time. Naturally, historians freaked out.

But who cares? If we sent a time machine with a camera back to the 14th Century to film a joust we just wouldn’t get it. We could watch in perfect accuracy and with no understanding whatsoever. Director Brian Helgeland should be given an honorary Doctorate in History from Oxford for his success in making medieval sports relevant in a way we can understand.

Likewise what the hell good is it to know your blood sugar is 147? Is that a good number? A bad number? That depends on the context doesn’t it? If you just ate a Fudge-fudge Walnut Brownie at the Elephant Bar in the interest of science, well, then a 147 is pretty fricken good. If you wake up at 147 after sleeping for 11 and a half hours, well, that’s not so good at all.

So the number is nothing. Actually, that would be a good add slogan for a CGM campaign: The Number is Nothing, know what your sugar is doing all the time in real time. No need to pay me for that one, MedT, just give me a couple year’s supply of your wonderful sensors and we’ll call it even. :-) It is the context of the number that matters.

Some of you know I used to be a Commercial Pilot (thanks a lot, diabetes). The instrument panel of an airplane is a wonderful thing. The first time you sit behind the yoke and strap yourself in you think, holy crap, I’ll never learn what all these gauges, switches, levers, and dials are for! But in reality the cockpit is elegantly simple. Most of the time you just look out the windshield and make sure that you are not about to hit anything (like other planes or the ground); and every minute or so you glace at the instrument panel and in a second or two all that cleverly designed visual information tells you how your plane is doing. You don’t even really think about it. Visual stuff connects to our brains in some sort of Zen like way that pure numbers don’t. If something is out of whack you’ll notice it. Trust me.

The graph on the new guardian is like a miniature aircraft instrument panel, but instead of telling you how a plane is doing, it tells you how your diabetes is doing. With a glance. Wouldn’t you like a diabetes cockpit of your own?

When you look at the display, you still get the old-fashioned number. Mine’s 176 right now. Nothing to be proud of, regardless of context. But this number is not floating in space either. It has context. The instrument panel is showing a six hour graph. I can see my OK, but not great, morning fasting number, and then my post-breakfast excursion. The hump is passed and my sugar is dropping back towards it’s target. If I’m dropping kinda fast I’ll also have an “down arrow” to alert me to that fact. If it’s dropping really fast I’ll get two down arrows.

Because we now have context in an instant, we can easily bring the power of CGM into play in a realistic way in our lives. We can monitor and intelligently, accurately, and proactively with minimum effort; and control our diabetes.

And, like an airplane, the new Guardian features an auto pilot of sorts. Should you neglect to remember to look at the instrument panel because maybe you are sleeping through a electronic medical records training or something like that, alarms go off if you start losing altitude too quickly. I really love this machine.

Other things from my wish list that I got: an option to leave my screen on all the time. Sometimes I don’t even bother to take the girl out of her holster. I just tilt her a little and glace at my waist. Ooops! Going up!

I can vary my thresholds depending on the time of day. Of course, like the original, I can choose what those thresholds are.

I’ve got a battery strength icon now! The old Guardian gave you no clue until it set an alarm off with the last sip of electricity, usually at 2a.m. The new girl is a battery hog, burning through a AAA in a week to ten days, but as she gobbles up the battery she keeps me in the loop about how much food is left on the table. This is the price that I pay for having my screen on all the time. I’m happy to pay it. If I didn’t already mention it, don’t go to bed with the icon on one bar. Bad news.

Back when dinosaurs ruled the earth, our CGM transmitters looked more like the thingies that soccer mom’s use to unlock their mini vans. The transmitter was expensive, short lived, and connected to the sensor with a short cable. It took up a lot of landscape on your bod. Now we have a sexy, small, and rechargeable transmitter. If all other things were equal (which they aren’t), this would be the reason enough to choose the MedT product over it’s competition. There is nothing evolutionary about this part of the system at all. This transmitter is completely revolutionary. The first time I saw it, I thought I was hallucinating.

It’s worth mentioning that I also have better telemetry with it as well. “Lost Signals” are much rarer with the new transmitter.
The software is drastically improved, which isn’t really saying much as the original was so completely abysmal. Still, it looks like the computer guys at MedT have really been trying to make some improvements in this arena.

Some seemly minor things that really are worth their weight in gold include a back light (yeah, the original didn’t have one, I slept with a red-lens flashlight on my night stand for a lonnnnnnnnnng time). I also now have a reminder that a sensor change is impending. Trend alarms for quick drops or surges have been added. The unit is water-resistant, which the old one was not. Water proof would be even better, not to nit-pick. It downloads it’s data way quicker. Getting Garage Door Guardian to download was a project that required packing a picnic. It is also lighter. For smaller folks, a 10 pound brick on their belt is annoying.

Last thing, and some will argue with me on this, I think it definitely looks cooler. Of course, like the software, they had no where to go but up hill on this front. That said, you could hardly say it is a cool looking device. This is no I-Pod. But is does look cool in a no-nonsense medical kinda way. All Guardian Real-Times come in dark greenish-grey. Maybe that’s called Smoke. I’m not sure. I’d rather have silver myself. But you can always doll up your CGM monitor with a host of skins that are now available to fit any mood, personality, or wardrobe. I do actually have a Zebra skin on my desk, but I’ve not gotten around to putting it on to see how it looks. Maybe the next time I go to the Elephant Bar I’ll dress for the occasion.

New Guardian also features a number of interesting on-board statistical functions that let you get an overall view of you control over time without downloading. This is far, far, far beyond the “BG Average” feature of most blood glucose meters. This is complex and interesting enough that I’ll hold off and devote an entire post to it in the future.

Things I never even thought to want include the sci-fi predictive alarms that actually work. I can’t tell you how cool this has been. In a million years I never thought we have CGM devices that would accurately predict the future. Talk about taking pro-active to the next level!

I did say there were two things that I didn’t get, and what upsets me most about these, is that a couple of steps backward in evolution we had them. Maybe evolution isn’t always progress. Garage Door Guardian was LOUD. Probably to be heard over the roaring of dinosaurs in those pre-historic times. It could also vibrate and squawk. I like ice cream with my cake. I don’t like to choose. There are times you will feel a vibe when you can’t hear. There are times you’ll hear a noise when you can’t feel a vibe. New Guardian will let you choose, but there is a lot of button pressing involved in changing, and odds are you’ll choose wrong no mater what situation you plan for.

Garaged Door Guardian’s alarms were also loooooooooooong. Real-Time’s alarms are dainty and short. Shake the earth. Wake up the neighbors. Our lives could depend on it. Actually, our lives do depend of it. We won’t be looking at our sexy instrument panels while we sleep: either at night or in training seminars. But over all, natural selection has delivered a wonderful new member of the species to us.

Now if we can only get the fuck-wads in the insurance companies to wake up and see the value of CGM we’ll be as good as we can get short of a cure.

Save the date

Our friends in Brussels (the IDF, the Blue Circle folks) have announced that the first United Nations observed World Diabetes Day will be November 14th! The theme for the year is Diabetes in Children and Adolescents. Any time you are feeling depressed about your diabetes, just think what it would be like if you lived in a Third World country.

The IDF’s key objective this year is to double the number of children covered by the Life for a Child Program.

They’ve asked me to add an attention-getting banner to LifeAfterDx to help raise awareness. I’m trying to (really Stephanie, I spent all morning working on it!) but I’m still having DSL issues that is making it all but impossible to upload much of anything. Hopefully the $#%&*@# phone company will get this resolved before World Diabetes Day!

ComLink

Black. Smooth. Small. I’ve seen something like this before. On-line, I think. Oh yeah, it was one of the things in the pictures of the alleged Roswell UFO wreckage.

Three-quarters of an inch thick. Inch and a half long. Looks more Lego than Techno. It is the ComLink, the Guardian’s voice when talking to the server farm back at MedT.

Today I decided to try it out. When I was using ParaPump, I used the BD meter to upload the pump data to the CareLink software. Guardian can do that too, but here is something new, so naturally I wanted to try it out.

It came in a red zip lock bag and was packed with one of those cute little mini discs that remind me of dollar pancakes. I assumed the disc had some sort of driver for the device. I slid the disc into the DVD/CD drawer of my aging desktop and waited for the spool-up noises. A window opened showing a….. PDF file? No driver software? Just an instruction manual?

I opened the PDF and my computer was instantly high-jacked by Adobe Systems, Inc.
No, I don’t want to check for updates, damnit! After closing 28 and one-half “are you sure you want to close this window” windows I finally got to my “manual.” In true MedT fashion, they used up eight pages to say “plug the sucker into your computer.”

The cable uses one of the old-school 9-pin mini serial ports that seem to have been eclipsed by the USB port. Lucky for me my computer is a dinosaur.

So I plugged the ComLink into one end of the cable and tightened the little screws. Then I plugged the other end into the computer and tightened the little screws on that end. Then nothing happened.

After 20 minutes I decided to go to CareLink and see what happened. I logged in with my username and password and chose ‘Upload Data from My Device.’

Three hours later the Java Plug in had loaded and I was good to go. I could choose a ParaPump, a Guardian, or a BG meter. I selected Guardian and was instructed to make sure the battery was good and that I didn’t have any alarms going off. See? Even the CareLink Software knows that no one can hear the damn alarms!

You next have to enter the serial number, either from the back of the unit or from one of the status screens. I went for the back. No cool numerology to be found this time. Next you choose the BD meter or the ComLink. Hmmmmm…. I wonder if they came up with this device when it looked like BD was going to go belly-up and take the meters and test strips that talk to Paradigm pumps with them? Next you must auto-detect or tell the system which port you are using. As I have no fricken idea, I opt for auto and hope for the best.

You are then advised to verify that the cables are connected and you are to get as far away from you PC as the cord will allow you. I’m told to click finish to begin reading my monitor.

I hesitate. Am I supposed to attach the ComLink to my girl? No way to do that. Presumably it is a wireless device like ParaPump. I don’t know how close the two devices need to be.

In the end I hold them together in my hand, press the enter key, and push off with my foot. My rolling chair rolls out into the middle of my library. The computer screen tells me that CareLink is setting up my ComLink. Cross your fingers, boys and girls.

Tick tock.

Tick tock.

Tick tock.

Tick tock.

Now I’m being told that CareLink is reading my data. Wow. That simple. Huh. That’s all there is to it. Plug it in. Go online. Follow the prompts. How easy is that?

It takes what seems like forever (like three whole minutes) to download my Guardian. When it’s done I select the daily overlay report to make sure the data is there.

CareLink opens a new window and churns the data for a few minutes then spits out a graph that looks like the monthly causality reports in Baghdad.

Holy, crap! That can’t be right! A twisting mess of colored lines, liked tangled wires in gutted airplanes at the junk yard. Only one trend to be seen: They are almost all high. All the time. Oh yeah. I guess that is right after all.