Happiness is…

Yep! It is a brand-spankin’ new Bayer DCA 2000+ A1C machine! No more shelping folks from the annex in all kinds of weather to the crowded main clinic lab. We can now do A1Cs in the comfort of my office while we review blood sugar logs. Oh joy! It couldn’t be more fun if I owned the damn thing myself!

Gusher

I’m sitting in my kitchen in my underwear, skin still damp from my shower. Outside the wind howls and moans.

With eyes barley open and brain not quite dealing with the fact it is actually morning—how can it be? It’s still dark outside for crying out loud—I peel open the vacuum-sealed pouch that holds my next sensor. The last one having run its course, it is time for a new one.

I pinch up a little skin on my left leg, lay the thick needle against my skin, and PUSHHHHH. The skin resists at first, then gives way. Like Excalibur in reverse, it slides into my body until the tape at the base of the sensor touches my skin. I pull the second tab, that covers the back half of the adhesive, and smooth the sensor tightly to my skin. I pull out the inserter needle and drop it into a sharps container.

Five minutes until I can plug the seashell transmitter in and cover the whole affair with an IV3000 dressing. For the next two and a half hours I’ll be without CGM coverage while the site settles in. For the first day the accuracy will be slightly less, but the trend will be accurate. For the rest of the run, the sensor will be frightenly close to my fingersticks; further proof that Clarke was right: a sufficiently developed technology is indistinguishable from magic.

I head to the library to check my weight. I’ve lost a few pounds over the last week or two, and I want to see if the trend is continuing.

On the way, I feel something wet, running down my leg. Water from the shower no doubt. Then I feel more, and more. I look down at my leg to see many rivulets of blood flowing from the sensor site, each branching out, each pulled by gravity downwards, each diverted by the contours of skin, muscle, and body hair.

Shit!

I cup my hand just below my knee to catch the little streams. Deb with have a fucking fit if I get blood all over the tan and cream Berber carpet (what were we thinking?). I hobble, hobbit like, to the bathroom and snag multiple Kleenexes and apply pressure to the sensor, which is now full of bright-red blood.

Double shit! Visions of dollar bills dance in my head. This little fucker cost me seventeen dollars and fifteen cents! Generally, if you draw blood, you can kiss off the sensor. I’ve had a few survive blood hits and run well, but in most cases they never read right.

That said, I can’t bring myself to rip it out and put in another one. I’ll run more fingersticks today to keep safe and if it gives me crazy readings all day I’ll put a fresh one in this evening.

Beeeeeeeeeeeeeeeeeeeeeeeeeeeeeeep! goes the microwave’s timer. The five minutes are up. I mop up the blood and plug in the transmitter. The green light deep inside the seashell flashes it’s morse-code. I’m here, I’m here, I’m here, I’m here. Where are you? to the monitor.

The monitor is listening. The telemetry icon switches from “no signal” to the funnel-icon that shows harmony in the universe between the two devices. Data flows through the early morning air and the mating dance of calibration and warm up begins again like some sort of Celtic wheel of life-death-and-rebirth.

The wrong injection

My cell phone rang at a little after nine at night. It was one of my patients. “Sorry to bug you at home, but I really fucked up.”

How so?

“I mixed up my pens.”

In a flash I knew what happened. You just took fast-acting instead of basal?

“Yeah. I’m scared shitless.”

No fear. We can fix this. How many units did you take?

“Seventeen. Of NovoLog. I can’t fucking believe that I did that.”

This guy is pretty insulin sensitive. Seventeen units is more fast-acting that he usually takes in the better part of a week. Bygones. Shit happens. Don’t worry about it. Tell me what you’ve got to eat in the house that’s sweet.

He had a few glucose tabs, a pint of Ben and Jerry’s chocolate ice cream and granular sugar for his humming bird feeder. No juice, soda, honey. OK, start eating the ice cream… No, all of it... then to Deb, Bade, fetch my lap top.

I don’t let any fear creep into my voice, but I know this is damn serious. I’ve got to stay clear headed and figure this out; and I gotta do it right. I’m thinking I need to get about 300 carbs into my guy to soak up the insulin.

He tells me the package of sugar he has reports four carbs per teaspoon. I call up the recipe math web site. OK. Three teaspoons in a table spoon…so 12 carbs per tablespoon…four table spoons in a quarter cup….so 48 carbs in a quarter cup….four quarters makes a cup…so a full cup of sugar has 192 carbs. I want you to mix a cup of sugar into four cups of water and dink it down. I chose 4 cups to make it quick and easy to get the sugar into solution. I stay on the phone while he mixes the concoction and drinks it down.

“It’s pretty nasty,” he reports.

Deb tells me you could have made some awesome lemonade if you’d only had fresh lemons. Do a fingerstick.

His BGL is 126. I wish like hell he had a CGM. Every diabetic should have CGM. And every pre-diabetic too, maybe it’d make them think more about what they are eating if they could see what the food choices they make are doing to their bodies.

We chat about marine archeology, a passion of his, while we wait to see what happens. He’s home alone. The hospital is too far for a safe drive with this much insulin coursing through his body. An ambulance ride will bankrupt him. And I know we can fix this.

In fifteen minutes his sugar is 218. I’m relived he’s going up.

My cell phone battery is giving out, making a strangled beeping noise every ten seconds. I ring off, promising to check on him every fifteen minutes until I’m positive we’ve got it under control.

Then I go off to find my emergency phone charger. This is a really handy little device. It’ll set you back about twenty bucks, but it can bring a cell phone back to life in under a minute using a pair of AA lithium batteries. Made by Energizer. Oddly enough, I found them at Home Depot. Amazing what you can come across buying paint for your mother.

I read a few pages of a biography of Sir William Mathew Flinders Petrie, the early Egyptologist. We recently took in a Santa Fe exhibit of artifacts he excavated. Very cool.

I call fifteen minutes later. He’s at 277.

I call fifteen minutes later. He’s at 294. This turns out to be the crest.

I call fifteen minutes later. He’s down to 243.

It’s getting late, things are looking pretty good. I instruct him to stay up until 1 a.m., to check his sugar every fifteen minutes. Thank God we were able to get a cheap strip program in place for our low income folks (ten bucks for 100 strips), and that he had just stocked up. If he was above 150 at 1 a.m. he could hit the hay. If he dropped below 150 at any time before that he was to call and wake me up.

I put the phone on top of the Petrie book and turned out the light. It had been a very long day.

The phone did not ring.

In the morning I called. Good morning, just wanted to see if you were still alive.

“Yeah, turns out you can’t get rid of me that easily,” his voice the normal gruff-but-friendly that I was accustomed to; no underlying tone of fear and borderline panic that had tainted it the night before.

Well, I think you’re worth keeping around for a while yet, where did you land in the end?

At 8 a.m. he was at 146.

So all’s well that ends well. But what if he had not realized his mistake? On the one hand we’ve got personal responsibility to keep our shit together, on the other hand the damn Novo flexpens all look alike. How many D-folk have killed themselves by taking the wrong injection? I doubt we’ll ever know, but recently there has been an interesting change in the pens.

It use to be that the only real difference in Novo’s three flexpens was the color of the injector button on the very tip of the pen. The label also had a very small patch of color: orange for Novolog, Teal for Levemir, and…. What the hell color is the Mix? Huh, we script so little of the mix I can’t recall the color off the top of my head. I’m thinking its some sort of blue, but I could be wrong. The buttons also have some brail-like ridges so you can tell the difference in your pens when you are trapped in a coal mine at midnight during a lunar eclipse. Always best to be prepared.

Recently, however, the pens have a new label, that takes up a full third of the pen, with prominent color. Hmmmmm….. I wonder how many wrong injections silently lead to that change?

Laugh or cry

Levemir basal insulin for Lee, $35 per month.
Humalog fast-acting insulin for Lee, $55 per month.
Synthroid for Lee, $15 per month.
Lipitor for Lee, $35 per month.
Lisonipril for Lee, $10 per month.
Zoloft for Lee, $15 per month.
Teststrips for Lee, $30 per month.
CGM Sensors for Lee, $175 per month.
Diltiazem for Debbie, $20 per month.
Metformin for Debbie, $5 per month.
Zzrtec for Debbie, $55 per month.
Zoloft for Debbie, $15 per month.
Teststrips for Debbie, $10 per month.

Being able to make your monthly medication co-pays: Priceless.
For everything else there’s bankruptcy.

(With apologies to the creative team at MasterCard’s advertising agency.)

PS: yes, for those of you who added it up, we really do make $475 per month in medication co-pays alone. That doesn’t include the cost of the insurance, doctor’s visits, OTC vitamins or assorted antibiotics when Rio brings some plague home from kindergarten.

A while back I joked about sitting on the curb with a cardboard sign that said Will work for Health Care. Now I’m finding it’s true; I’m quite literally working for my health care, with well more than half my clinic income going right back into the health care system.

The worst job in the world

I’ve always had a hunch that the worst job in the world would be being the mother of a Type-1 kid. Now I have definitive proof of that.

It happened at our Type 3 group meeting. The recently retired mother of a healthy, full grown Type-1 was talking about her feelings, still raw after thirty years. “I felt so…..Guilty” she told the group.

Why, I asked.

“Well, I gave it to him,” she said.

That’s ridiculous, I told her. He didn’t get diabetes from eating too many Three Musketeer’s bars. It was in his genes.

“Yes, but they were my genes!”

Wow. I was stunned. I knew how scary it is for Mom’s of young T-1s. Constant worry as they try to guide their children down the tight-rope between hypos and DKA. Dealing with idiot school officials. On the pone all the time checking sugars and making decisions about insulin. Sleepless nights.

It had never occurred to me before that a mother might feel personal responsibility for the genes she passed on to her child. What a burden of unnecessary guilt to carry for 30 years.

But I’ll bet this is one hell of a lot more common that any of us would dare to guess.

I think we need a second, special mother’s day for those ladies who have the worst job in the world. On D-day this November I want all of you to send a special card to all the Moms of T-1s you know. They need to know we love them for all they do, and none of us blames our Mom’s for “giving” us diabetes.

Has the ADA abandoned us?

It was support group time. “How many of you belong to the American Diabetes Association?” I asked.

No hands were raised.

Huh.

“How many of you use to belong?”

Every hand in the room went up, including mine.

All the ADA does in my state is have diabetes walks to raise money. At the clinic we can’t even get their help with education materials.

Maybe it’s time for a new organization to represent us.

So this is highly disturbing….

I’ve got this brilliant patient with a long history of managing non-profit organizations. We’ll call him Victorio, which doesn’t even sound anything like his real name. He’s got a resume that would make any board of directors drool. He was a powerful and influential figure at the Round House (what we New Mexican’s call our state capital, ‘cause it’s a round building--in session it’s sometimes called the Merry Round House).

Then, a few years back, he got diabetes, and got bad medical advice, and got very sick. He dropped out of the scene for five or six years.

Then he found us.

About a year after coming to my clinic I’m proud to say he is once again healthy, happy, and ready to work. I saw him about a month ago, he had many resumes out and was cheerful over his prospects.

Today, when he came in, he was so depressed that I knew something was wrong the second I saw him. Que paso? I asked him.

Victorio had gone in for an interview. It seemed to be going well, and he personally knew a number of the board members. It was an outfit whose cause he believed in, and he felt he was a good cultural fit for the organization.

Then at the very end of the interview, something unexpected and strange happened.

“How is your diabetes?” Asked one of the interviewers, “I had heard that you had been very sick.”

After a shocked moment Victorio replied, “Very well, thank you for asking.”

A week later he received a form letter thanking him for applying, but the board had selected another applicant. Well, these things happen, thought Victorio. Until about a week later when he discovered they had hired a very young man with no relevant experience.

He made some calls and finally an old friend, who told him he’d deny the facts if ever asked, told Victorio what really happened behind closed doors. The non-profit decided that they couldn’t risk taking on my patient because of what having a diabetic on the payroll would do to their insurance rates.

(Collective cry of rage from blogosphere.)

Now this is disturbing on so many levels I don’t know where to start. Forget about the discrimination issue for the moment, and the violation of federal law it represents. It saddens me that insurance has gotten so out of control that its cost even figures into hiring decisions at all. The fact is the board is probably right. They are a small non-profit. They could go under if their health care costs go too high.

But what does this say about our society?

My patient loses.

The non-profit loses, not being able to take advantage of Victorio’s skill, intelligence, and experience.

The population served by the non-profit lose, by not having the best management to guide the mission.

Everyone loses.

The Real Time revolution

(Note: OK, nobody steal that title ‘cause I’m using it for my upcoming book:
The Real Time Revolution:
the art and science of controlling diabetic blood sugar using Continuous Monitoring Systems
….yeah, I know that the sub-title is a little long but there is a modern trend of plugging all the possible Google search words into your subtitle to try and drive book sales.)


The revolution started as they often do: with violence. I was so pissed off with the Guardian that I wanted to throw her against the wall.

I had just spent two weeks entering every move into her “memory.” Every fingerstick, both calibrating and non-calibrating. Every carb that went into my mouth. Every drop of insulin that went into my body. I weighed all my food and made copious notes in my food log. I was preparing for the ultimate post-game.

I was in control freak… errr…control enthusiast mode.

I logged on to CareLink, plopped the ComLink in my lap and downloaded, and downloaded, and downloaded, and downloaded, and…

Eventually, in the fullness of time, with the passing of the seasons, it was done. I eagerly ordered up a batch of reports and printed them. They were filled with red “no data” and blanks where the carb info and insulin numbers were supposed to go. Virtually all my carb and insulin markers were gone. All I had was SG (Sensor Glucose) data. I called up the log to see what happened. All the data was there, but it was not populating the reports.

Following anger, depression set in.

For the next week I didn’t enter anything. Why bother? It’s a pain in the ass, and it did me no good.

Then a number of things happened to me in rapid succession. I don’t know if I mentioned that I’ve felt like crap for some time. Months, maybe longer. Recent blood tests, done months late ‘cause I owed the hospital lab for ordered tests that weren’t covered by insurance so they would not accept more samples from me until I was paid up, revealed that I was VERY seriously over-medicated on the thyroid front. So that was adjusted. And my anti-depressant was doubled ‘cause I’ve been twice as depressed as usual.

Then I was exposed to the raw emotions of the survivors of T-1 who died from a hypo that may or may not be connected to a pump malfunction; but at the very least was exasperated by the worst possible medical advice. (Editor’s note: I’m working on this story and will post it in a few weeks. Stock up on Kleenex, you’ll need it.)

Anyway all of these things piled up and I re-discovered the Religion of Diabetes (ROD?) and became, once again, a Born Again Diabetic (ironically, “BAD,” which gives a whole new meaning to Bad to the Bone, given that it has recently been discovered that the skeletal system plays a major role in glucose regulation to the point that it may have to be considered part of the endocrine system).

(Oh yeah, that’s another title you can’t steal. I’m using it for the other book I’ve been charged with writing. So sometime next year you’ll have to add “Author of The Real Time Revolution and The Born Again Diabetic” to my tomb stone.)

So with a new sense of purpose I strengthened my will-power and started eating sensibly. While my Type-3s feasted on pasta I ate salad. While they had pumpkin pie in front of me, I drank water. Normally the first to answer the siren’s call of carbs I boldly walked past the brownies in front of my boss’s office and turned down a sample of allegedly sugar-free girl scout cookies.

Very quickly my sugars went from this:

To this:

With most of my meals around 15 or 20 carbs I’m nearly excursion free. My trace almost looks like a normal person. Almost.

But do you want to know the best part?

I feel good. Really GOOD. I haven’t felt this level of energy and mental clarity for…. Well, over a year anyway. I recovered from my EBay obsession (although I haven’t actually gone there for a few weeks to test my resolve, I’m not a complete fool. Not good for alcoholics to just “sniff” whiskey after all.) I have less aches and pains. I’m sleeping better. My mood and humor have recovered and I’m once again full of restless mental and physical energy that have always driven me forward under full sail.

Now, will feeling GOOD be enough to resist temptation in CarbLand? Time will tell. I haven’t been to the Elephant Bar since becoming BAD.

Coming to T-1 as an adult, I’ve got a lot of bad habits to overcome. Peers who’ve had T-1 since kid-hood generally agree as adults that it was easier to grow up under a set of rules than to change as an adult.

But some how, in the middle of this, I still didn’t start re-entering data in the Guardian. Unplanned, un-premeditated, and unconsciously I started using the Guardian Real Time in real time. I didn’t do post game. I took real time information and made real time decisions.

Damn, is it ever working.

On the second night of decent day-time sugar control I woke up too low for my taste and mental security. I ate my breakfast bolus-free to get back up above 100. The next night the same thing happened. I backed off my Levemir from 20 units to 18. And then to 15. Then 10. My total daily insulin is mere sips.

I am beginning to suspect that there is an un-discovered link between total daily basal requirements and total daily carb intake. But that science will have to wait for another day.

On the way home from work one day this week E asked me what I was eating. Quarter cup of Kashi with a sausage patty for breakfast, two low-carb SlimFast shakes at the clinic, and a salad for dinner.

“Huh. So you get to choose between your blood sugar killing you or starving to death? Is that what it comes down to?” she asked.

Yeah, pretty much.

Actually, I have a PLAN. I’ve put on almost twenty pounds over the last year. I’m somewhere in the mid 190’s now. I feel best between 175 and 180. Of course at that weight I have to put up with both my mother and wife insisting that I’m TOO thin. It’s nonsense, but they still remember the pre-diabetes fat man.

So I’ll coast down on weight until I close in on my goal. Then I’m going to try the Hunter-Gather Diet. I’m going to eat six or so small low-carb meals throughout the day. By keeping the carbs low I’ll avoid the excursions. By keeping the number of meals high I’ll pull in enough calories to avoid starvation.

The only risk is that I’ll die of boredom.

Oh yeah, and before the comments start piling up on the protein front let me tell you a little more about my salads at dinner. If the two T-3’s are eating something carbelicious then I’ll have a nice heaping pile or Romaine or Green Leaf lettuce with baby carrots, red bell pepper, sunflower seeds, and chunks of grilled white meat chicken. (I grill it on the weekend to stock up for the week, with heavy pepper, garlic salt, and paprika—you wouldn’t want to eat it straight, but it’s great on a salad.) On the side I have a third-cup cottage cheese, some slices of hard salami from Sam’s Club, and macadamia nuts from Trader Joe’s. If the T-3s are having fish, beef, pork, or chicken then I’ll join in on that portion of the meal and down-size my salad, passing on the dreaded high-carb side dishes.

Anyway, back to the subject at hand: I had wanted to flesh out some more detail on using the Guardian in Real Time to control the blood sugar in Real Time, but I think I’ve exhausted everyone’s attention span just setting the stage. I’ll have to blog the rest later.

Or maybe I’ll make you buy the book.

Not the world we grew up in

So I picked Rio up from kindergarten. Tell me about your day.

“We had a fire drill,” he told me. “We all lined up and left the building. Then we practiced a Code Blue.”

Code Blue?

“Yeah, it’s if someone breaks into the school or something. We all have to hide under our desks and not make even peep of sound. And the teacher locks the door and closes the windows.”

Christ, what’s the world come to? Kindergarteners rehearse for school shootings. A wave of mixed emotions wash over me. I’m glad they have a system in place and practice; I’m sickened that they need too.

I’ve remained silent too long. “Daddy?”

Hmmmmmmm?

“Do they have Code Blue’s at the clinic?”

Yes, but we call them Code Blacks. I recall sitting on the floor, doors locked, blinds down, pondering the likely lack of bullet resistance of my office walls.

“Well…. Well that’s confusing. Why would they call a Code Blue a Code Black? That doesn’t make any sense.”

Well, in medicine, when someone has a heart attack we call it a Code Blue. So we had to pick another color for lock downs.

“Well, I think everyone should call them Code Blues so little kids don’t get confused.”

I say a quick prayer for all children everywhere, and then we drive on in silence.

“Isn’t Friday a good day for ice cream?” asks Rio.

Indeed it is. I can think of nothing I’d like better at this moment than to share a cherry dipped ice cream cone at DQ with my little son.

A poor role model

At a recent group meeting of Type-1s at the clinic I was accused of being a good role model. I beg to differ. I think I’m a crappy role model and I told the assembled mini-throng exactly that. They all protested that I was solely responsible for lowering their collective blood sugars.

They don’t give themselves enough credit.

There’s a lot of things that could go on my tomb stone, but role model is not one of them. My last A1C was 7.85, I eat Fudge-fudge Walnut Brownies at the Elephant Bar, my SG plots look like earth quakes. I sometimes eat French fries. And Oreo cookie blizzards. I supersize my pasta. I smoke. Sometimes I drink. We all know I swear.

Do what I say, not what I do.

I’m a very poor role model. A good cheerleader, yes. A walking encyclopedia of diabetes facts and fictions, maybe. A compassionate empathic shoulder to cry on, absolutely. A religiously passionate diabetes advocate, hell yeah.

So what should go on my tomb stone? Well, it’s gonna need to be a big stone!

Loving husband and devoted father. Photographer, writer, thinker. Pilot. Master darkroom printer. OK. Well, maybe not that big a stone after all. But go ahead and add one more thing:

Type-1 Diabetic.

Yeah. Go ahead and put it on my tomb stone. I don’t mind. I’d love it if my great-great grand children could stand at my grave and say, “Wow, poor Great-great grand Dad. He actually had to live with diabetes. How primitive it was back in the dark medical ages! They had no cure. They actually had to pay for their health care! Can you imagine? Do you think it’s really true that they actually had to plug their computers into the wall to charge them and their cars ran on some kind of black mud pumped up from underground?”

Yep. I’m proud to be diabetic; but I pray that I’m the last generation.

Where does time go?

“Where do days go when they are over, Daddy?”

Huh?

We were on our way home from Kindergarten. What do you mean, Baby?

“When a day is over, where does it go?”

Ummmm…..well, it doesn’t go anywhere. When it is over it is in the past. It’s gone. It’s only in our memories.

“So when a day is over, it is dead, like our ancestors? Only left in our minds?”

Wow. I’m having a college-level philosophy discussion with a five year old, and he has the better grasp of it than I do.

Feedback

Yeah, yeah, yeah. I know, I know. I’m really, really, really bad about moderating comments. I actually went on my very own blog to try to leave a counter-comment the other day but it’s been so long the site doesn’t remember my logins and neither do I. How embarrassing. That said, there were a few things so powerful or wonderful or in need of an answer that I decided the best way was to post directly.

By the way, just because I’m lazy about this doesn’t mean I don’t like getting comments. I love getting comments. I know from the hit counters I got lots of readers. Just not many commenters. Probably ‘cause I lazy about cultivating it. Comment away, I do like to know what you all are thinking.

Rich, who has asked twice: a cherry slice is a candy made by Sathers. They are like the more common orange slices (wedge-shaped gum drop type things covered with large white sugar crystals) but in cherry flavor. Sort of hard to come by. Believe it or not, I get mine at a hardware store! Portable, tasty, and brings my BGL up without an excursion. Also, I love your description of my blog as “high end reality internet!” So cool! Thanks. I’m going to get a T-shirt that says LifeAfterDx: it’s high end reality internet. And one other thing that Rich wrote has stayed with me. Eight words more powerful than poetry. “Diabetes will be like polio without a vaccine.” Wow. Chills down my spine.

Bernard who wants photos. I’ve had some real DSL troubles that makes loading images near impossible; plus it involves more time, which I’m chronically short of. On top of that, I’m not feeling much need too. I like to paint with words, and there are no shortage of images of this gear at MedT’s website. But I’ll try harder to include some. It’s not like I don’t know how to use a camera, after all.

Itesseract: thanks! I loved the image of me being “some famous doctor writing revolutionary books about diabetes treatment” rather than some poor slob with multiple jobs awash in overdue bills!

Actually, that said, I’ve been asked to author a couple of diabetes books. So that’s my project for winter. One will be on CGM, of course. The other is a guide for “Born Again Diabetics,” basically a refresher course of all the stuff you use to know, but have forgotten.

As to all the flak I created in musing about T-2’s on oral meds using glucometers; I’ve come around. I think more people benefit from them than not. Also, the cold fact is that if you live with diabetes long enough you WILL be taking insulin. Might as well get good habits from the get-go.

I updated already on the cat situation, so that should cover all of that feedback.

Sorry, Marina, I still disagree with you. Health care is a basic human right. Most people with chronic illnesses have done nothing to bring it upon themselves. It is unfair to make them carry a greater burden money-wise just because of their genes. In a fair and just society we collectively share the costs of civilization: that includes education for all, common defense from all perils (police, fire, disaster, and military), quality transportation networks, well ordered airspace for safe flight and, healthcare. I’m sorry you have no interest in your neighbor. Even if he “can’t be bothered to exercise and eat right.” Let’s assume that is true. You are only interested in your pocketbook, right? I’ll cost you less to get him free health care now; ‘cause you’ll end up paying for his dialysis later. Fact is, where I work, money is short. People will buy beer before they’ll spend a dime on their own health care. It would be nice if we could fix that, but changing culture takes decades. Let’s do the right thing for our neighbors. Let’s make them healthy and then create a culture of health. The fact that we can save money in the long run by spending now is just icing on the cake. I’m truly glad you can cover your own health costs while being self-employed. But wouldn’t you have rather spent that money on your family?

But to answer you question on a later post: I chose the CGM over the PUMP as a choice of LIFE over DEATH. I do no feel lows and I’m “brittle.” I did feel one low a while back, but 99.9% of them ambush me. Last week I had a 37 that was a real bitch to turn around. Deb’s writing a post about that rather scary night. When she gets it done I’ll post it (writing comes harder to my wife, so it may take a while). A pump is just a delivery device. You can get control with any delivery device. Granted, a pump makes life waaaaaaaay easier; but in my case the CGM was necessary for daily safety, the pump was not. Also, I can (in theory) get better control with the continuous CGM info and the shots than I can with a pump and random fingersicks.

I’m more like Scott so far: a happy ex-pumper. My control still isn’t as good, but I’m making progress; and my life is easier without something plugged into me. You do have to stay more on the ball with shots than a pump, but that may not be a bad thing. As to your musing on the long term fate of NPH, given what we know about the politics and profits of big pharma; you already know that answer. The clock is ticking on NPH.

Thanks for all the remember-the-damn-basal tips. I got it down now (knock on wood).

I dunno Allison, I’ll bet everything you do is beautiful. ;-) Injections too. Actually, no one but diabetics notice injections. I was freaked out when I went back to shots, but in fact, with many, many, many public injections under my belt…well above my belt actually… no one has even given me a second look. I was actually a little bummed. The fact is, most folks just don’t really pay that much attention to what’s happening around them.

Scott, I too shoot through clothes, sometimes. But I find that it dulls the needle too quickly and I really like to stretch them as far as possible. As far as fear of needles, most folks I’ve put on insulin marvel at the fact it ends up being no big deal. The most common comment: “The fingersicks hurt more!” That said, if big pharma had the sense to develop inhaled basal first, it would be a good seller. The current inhaled insulin is fast acting. We almost always start T-2’s with basal. By the time they need fast-acting shots are no big deal. I wouldn’t personally invest even 2 cents in inhaled rapid. (But it dose work just fine!)

Jenny: yeah, portion size at fast food can vary, but at least you’ve got a starting point with the carb data. But don’t worry about Taco Bell, I only eat that crap about twice per year. But when you live as part of a family…..

Eric (commenting on the LARGE square marking a fingerstick in MedT graphs, and pointing out that the oversized squares could be a way of showing the inherent 20% error range of a fingerstick)…hmmmm, I had not thought of that. But I still think they are trying to be sneaky.

Frayed Edges….sorry I made you cry. But you are not all alone. You’ve got lots of “brothers and sisters” out there. Way more than you can ever guess. We’re all here for you.

Chrissie in Belgium: of course we are related! We’re all the same tribe, us D-folk!

Jen. Antecubital. Thanks! How could I have forgotten that???

Re: forearm testing. Should be banned. It’s not safe. The forearm lags waaaaaaaaaaay to much, especially for hypos. I’ve only let two patients test on forearm. One was a potter and the other had such horrible neuropathy in his hands that fingesticks were literally torture. In both cases it was forearm or they wouldn’t test at all.

And now we return to our regularly scheduled program…

A victory for the craft-impaired

My Dad’s solution for fixing anything broken around the house: call the handi-man. He was a brilliant college professor. So was my grandfather. My wife, who has a PhD in Common Sense, has noted that the smarter people are, the less real-world ability they have.

I’m not quite sure where she is plugging me into that equation.

But I’m too poor to afford handi-men so I muddle through one disaster-to-the-next.

Anyway, one of my early childhood memories was of my Dad trying to fix a lamp cord to replace a faulty switch. He cut through the cord with his trusty Swiss Army knife while the cord was still plugged into the wall.

He literally blew a chunk out of the knife blade. It vaporized a section the size of a pea with a spectacular flash of blue-white sparks. Cool! Do it again, Father!

That was before Al Gore invented the internet, so we had to make a pilgrimage from Durango, where we lived, to Denver—the nearest outpost of civilization where one could buy a new Swiss Army knife in those days.

Of course, now we have the internet. I don’t recall if I mentioned my latest addiction: surfing Ebay for tobacco pipes. Over 5,000 out there are needing a good home. Actually, that makes me kind of a hero, don’t you think? It’s kind of like taking in stray cats or abandoned children. I’m creating a Pipe Shelter.

Anyway, thank God for Esnipe. I was able to delete most of the bids I placed in a moment of weakness. I did make one good buy I want to tell you about, however, you need some back ground first.

So last month was my birthday. My assistant left a present for me in my car. I found it after she had left for the day. It is by far, the most beautiful, wonderful thing anyone has ever given me. A pair of book ends with a four-masted schooner. The front half of the ship sails out of one end of the book end and the back half sails in. The ship has been bisected by the books. The detail is incredible right down to the rigging. The wood is gorgeous dark reddish-brown, trimmed with bright shiny brass.

It was too wonderful to put on our library shelves. I wanted it near by, where I could enjoy its details. I put it on top of the Craftsman-style end table that sits next to my desk in the library hiding my computer printer.

The table top was already home to the only Nautical accessory I previously owned: a brass sextant.

Back to Ebay, a week ago. Surfing for pipes, careful not to short-circuit my keyboard with drool, I found a seven-day pipe rack. These are designed for serious pipe smokers who “rotate” their pipes daily, ensuring that each one gets it’s optimum minimum of two days rest between smokes. It is circular. The top of this one looks like a ship’s wheel.

Seemed perfect for my table top.

I got it for a little over ten bucks.

When it arrived it was kinda sad looking. The brass fittings that mimic the multiple handles that ring a sailing ship’s wheel were tarnished to the point of being indistinguishable from the color of the wood; which was a ugly, yellowed, faded once-upon-a-time walnut. Still, as they say, the thing had great bones. I was convinced that it was a diamond in the rough.

I took a Dremel tool to the brass. They polished up to an astounding bright-burnished brass, shimmering like a precious metal.

Then I started sanding the wood to get the old finish off. And sanding. And sanding. And sanding. And sanding. And sanding. And sanding.

I tried various power tools with no luck. The thing is a mass of curves and depressions. The base has a smooth oval recess for each pipe’s bowl to rest in. There are holes for the stems. The ship’s wheel as a sexy depression running around it. The base has a grove running parallel to the table. The central stem is a tapering rod.

All of the sanding, sanding, sanding, sanding, sanding, sanding, sanding, sanding, sanding, needed to be done by hand. I made slow and steady progress between hand cramps. I started with corse sandpaper, moved to medium, and finished with fine. I stripped off all the nasty old finish and restored the wood to a buttery-smooth surface. It took two days.

Then I used a combo stain-urethane to finish the job. The can said for best results to coat it once, sand it AGAIN and re-stain. Yeah right. It looks brand new, I’m stopping while I’m ahead.

I’m really, really, really, really proud of myself. It looks wonderful, and we don’t have to go to Denver to replace anything.

Except, maybe, my cramping hand…

Washing hands—it’s not just a bathroom activity

“J” works for me. He’s a T-2 who was originally one of my patients. He came to me from a extraordinarily wealthy part of Colorado known for it’s good health care. He came to me as a total train wreck. He suffers from every known diabetes complication except death.

As I got to know him and study his medical history, as I better understood his intelligence and personality, a radical idea came to me. I went to my medical director and told him, I think we should treat this guy like a Type-1. After lengthily discussion I was given leave to “promote” J to a T-1 and I started MDI therapy on him. For those of you who don’t know the slang, MDI stands for Multiple Daily Injection. A person on MDI takes one or two daily basal insulin shots to hold the line at night and between meals, and then must take a fast-acting shot every time they eat anything. It is the only way a non-pump T-1 can stay alive. It is a lot of work, but you can get some stunning results control wise. MDI is best for control enthusiasts who have embraced their diabetes as the interesting and time consuming hobby that it is. On top of fast-acting for food or drinks with carbs, you must also take fast-acting to correct for high blood sugar when you’ve been ambushed by lurking carbs. Advanced users can also adjust on the fly for high or low blood sugar by increasing or decreasing the amount of insulin taken with a meal.

Jim took to MDI like a fish to water. His control is now better than mine, and we now have a number of motivated T-2s on MDI. All doing really, really well.

About the same time that J became both a born-again-diabetic and in great control, we had a booth at the “Diabetes Day” in the rotunda of the state capital. I had gotten my paws on one of the 10 booths available to all of the diabetes programs in the state back when I was still the super-driven religious zealot of diabetes education. Three months later, I was a cynical burn-out with a booth and no clue how to use it.

We decided on a public screening. My Executive Director suggested I take along a few patients to talk to people about their experiences at the clinic. She quickly followed that suggestion with a not-so-short list of…. difficult…. patients that I was not to take.

Any way, J was one of four who spent the day with me. We screened 350 people. It was crazy. I couldn’t keep up and he jumped in to help with the fingersticks. He came to life. At that very moment, our Peer Educator program was born.

J is now paid by the clinic and is my left-hand-man. That’s because I already had a right-hand-woman. He works the Thursdays that I’m gone and he fills in for me when I’m sick or Rio has a day off school. To keep his education curve moving upwards he also works with me half day Mondays.

So this Monday J had a low.

He felt it coming on as he left the pharmacy with some insulin samples. On the way past our Executive Director’s office he spied a birthday cake on the carb counter (out boss has a sweet tooth and enables herself by sharing with the staff). Figuring he needed sugar anyway, and figuring that birthday cake sounded like more fun that glucose tabs, he snatched a piece and ate it on his way across the parking lot to the Annex.

When he got to my office he reported in and told me what was going on. “I’m still feeling symptomatic,” he told me.

Do a fingerstick, I said, handing him a meter and a disposable lancet.

His hands shaking, he slipped a test strip out of the vial and slid it into the meter. I twisted the safety off the lancet for him and he held it against his finger. Snap! A small squeeze and a fair-sized drop of blood appeared. He held the tip of the strip to the blood droplet and the strip wicked in the sample. Tick-tock. Tick-tock. Tick-tock.

157.

Huh. “That doesn’t seem right,” said J.

Test again.

“Let me wash my hands first.”

Jim stepped out and washed his hands in our wheel-chair accessible bathroom.

He came back and we repeated the process. Snap! Tick-tock. Tick-tock. Tick-tock.

56.

Holy crap! Here, I handed him a three-pack of glucose tabs. Eat them all.

It was a bad ride. We had a hell of a time turning around the hypo. (Later his wife reported to me that at breakfast J couldn’t remember if he’d taken his bolus or not and apparently double bloused. He now has a Lilly Memoir pen that keeps track of such minor details for him.)

After the glucose tabs we did dried banna chips. Then an entire bottle of Oral Glucose Tolerance Test solution.

You’ll be glad to know J is still alive. I just read about a guy who was given U-500 insulin at a Wal-mart instead of his usual U-100. He wasn’t so lucky.

Any way, back to the WHOLE POINT of this post, which is the 157 fingerstick followed by the 57. WTF? you may be asking. Here is what J and I think happened: there was still sugar on his finger from eating the cake, probably from the icing. When he lanced his finger, the sugar on the surface mixed with the blood and gave him a false high. Crazy!

So, do what we are all supposed to do, but we never do: wash your hands before you test. If you are where you can’t wash at least lick off your finger.

Unless your mouth is full of cake.

No such thing as a free cat: The next chapter.

So I’ve been writing about Diabetes for years. I talk about technology, policy, economics. I rant and rave. I joke and scold. I share the good and the bad. Sometimes I just stir the pot to see what will happen.

But guess which post generated the most email in my inbox?

Nope.

Nope.

Nope. Guess again.

Yep. That’s right. My post There’s no such thing as a free lunch, which detailed the story of how our cat Khaki adopted us. Apparently there is some sort of connection between D-folk and cats. If you are a diabetic reading this and a cat does not live with you­­--you are very much in the minority. I know dogs can be trained to warn of hypos; maybe we should focus on training cats. No wait a minute. What am I saying? Cats can’t be trained. They are what they are. Independent. Intelligent. Curious. Wonderful. But most certainly not trainable.

So I got hundreds of emails full of cat advice. Stop worrying. We did not use the flea collar. We got her all her shots. Yes, she’s got special Siamese food. Royal Cannin Siamese 38. Not cheap at all, but she likes it, it treats her well and I should be grateful she’s not one of those finicky types who only eats canned food.

She’s grown at lot. Long and lean. She’s frisky and goes into “attack cat” mode frequently.

And she’s now “fixed.” So all of you can stop fretting about that. Set us back $176.87, including an optional blood chemistry panel that checked her liver function etc. to make sure the anesthesia would be safe.

When they sprung this option on us a the Vet’s at the last minute Debbie and I looked at each other and shrugged. In for a penny, in for a pound. Khaki had chosen to entrust us with her life by joining the family. It would be disloyal in the extreme to get cheap with such a precious gift. We signed off on the extra fee.

I got a print out of the feline blood panel they ran. I look at human blood work daily. I found it fascinating to compare the cat to the man, as it were. We are not-so-distant cousins after all. Cats and people share more than most people can ever dream.

It knew that of course. I remember a professor telling me that the girl next to me and an oak tree share 99% of the same DNA. It is the little differences that make us tree or person.

But back to cat blood.

Many of the things they checked are the same things the Dr. E ordered for me earlier this week. The reference ranges are quite a bit different, however. For instance, Khaki’s blood glucose was 111 mg/dl; actually better than mine, but in her case within the normal range of 74 to 159 for cats. I guess you’re not a pre-diabetic cat until you’re over 159. Huh. Boy, cats get all the breaks.

The vet checked her Creatinine (a marker of kidney function), her ALT and ALK Phos (liver); sodium, potassium; and all the various goodies that make up a complete blood panel: white blood count, HCT, HGB, etc., etc.

Basically, the Vet ran the same test on Khaki that Docs run on humans.

For $41.60, a hell of a lot less than I paid.

Hmmmmmmm…

Maybe next time I need a blood draw I should go to the Vet…..

Your insurance cares about you--Act 3

I slip the key into my mail box, but it won’t open. I fiddle with it. The lock is unresponsive. Like granite. It’s the little things that go wrong that take years off your life.

Then I realize that I’ve put my key in the wrong box. I pull the key out and slip it into the box to the left. It opens without difficulty. No moths fly out. A single envelope beckons me. Not even any junk mail. How have I fallen so far off the radar that I don’t even get junk mail anymore?

It’s from Presbyterian Health Plan. After my pleasant chat with Lujan yesterday I experience no nausea upon getting a letter from my health insurance.

I open it on the way back to my car. Riiiiiiiiiip. No telling how many Americans are run over and killed while reading their mail exiting Post Offices.

This letter is from Lisa. Her title is Grievance Research Specialist. Huh. I don’t envy her job.

The letter summarizes my sharp comments to Life Masters. She thanks me for sharing my concerns with Pres. They value my opinion. They’ll treat my complaint as an opportunity to make changes to give me better service. Some one will call me shortly.

Well, the message arrived before the messenger in this case. But still, I gotta admit, I’m impressed with Pres. Remember this started with a short tempered vent to a sub-contractor. My message was relayed and someone paid enough attention to research it.

Maybe I miss-judged Pres. Maybe they aren’t the faceless cold monolith that is Blue Cross. I still don’t trust them, but maybe I’ll be able to live with them.

I tell my new Dx’s that living with diabetes is like living with a tiger. If you feed it, groom it, never turn your back on it; you can live with a tiger. If you neglect it; it’ll pounce on you and rip you to shreds.

Maybe insurance is the same way. Diabetes and Insurance. You can live with both; just don’t turn your back.

Your insurance cares about you--Act 2

The cell phone rang as I was unpacking the car. We’d just returned from a kindergarten field trip to McCall’s Pumpkin Patch. We were wind-blown, exhausted, and I was still trying to get hay out of my ears.

Deb answered then held the phone out to me. For you.

Juggling three pumpkins, I took the phone, which then made a strangled squawk to tell me the battery was low.

It’s Lujan from Pres. She a clinical nurse something or ‘nother

“ Hi, William, I’m just calling to follow up on an email we received from Life Masers. Apparently you don’t want to participate in our new diabetes program because you feel that we should be spending the money on providing adequate numbers of test strips instead?”

Yeah, that’s right. I’m sure your records show I’m a type one on multiple insulins. I should be testing ten times a day.

“I couldn’t agree more,” said Lujan.

I dropped the phone.

After setting down the pumpkins, picking the phone up, and plugging in to a charging cord, Lujan and I had a pleasant conversation.

Turns out Pres will allow up to 300 test strips per month for T-1s. Catch is you pay a co-pay for each box. That said, so long as you use their preferred type (AccuChek Aviva) they’ll give ‘em to you at $10 per box; which is really a pretty good deal. Of course, you have to get all 300 at once so you need to cough up thirty clams at the pharmacy. (Being a weeeeeee bit behind on my pharmacy tab I’ve been demoted to pay-as-you-go. OK, so maybe 690 bucks isn’t a weeeeeee bit.)

If I was still able to use my CoZmo pump they’d actually pay for FreeStyle strips. Wish someone had told me that back when I was still using my pump. You need a prior-auth, but it is always approved. Sigh. Why does insurance have to be so complicated?

She was sorry to hear I’d been caught in a plan with poor Durable Medical Equipment (DME) coverage. Apparently there are “thousands” of different Pres plans. Some treat D-folk better than others. “It’s a nightmare,” she tells me. More support for my fundamental belief that good insurance is really only offered to those that will never use it.

I didn’t think to ask her the question every pumper in the world wants an answer to: why the fuck are infusion sets considered durable medical equipment? There it nothing durable about them at all. Ya’ throw ‘em out every three days. Or four. Or five. Depends how poor you are and how much you are willing to risk an infection.

Back to teststrips. Lujan told me that teststrips are the sinlge largest expense for Pres of all medications. She also said they have been giving D-Folk more strips and tracking A1Cs to see if they improve with greater testing. Her official line is that Pres is willing to pay more up-front to save money on complications later; but at the same time the British study indicating that testing may be a waste of time is casting a long shadow. I feel a collective shiver across the diabetes landscape as that cold wind continues to blow down from Brittan.

She also tried to get me to switch from Humalog to Novolog; a change of $55 per box to $35 per box of five. Yeah, I used Novolog for years, but it isn’t doing the job anymore. The Humalog is. OK, well, nothing you can do about that.

She also told me that for some seniors caught in the “gap” of their Part-D coverage, many providers are having their Lantus/Levemir users go to Wal-Mart and buy ReliOn NPH out of pocket. This does not require an Rx. Feedback Lujan gets is that the old-school NPH is doing the trick for a lot of folks. Hmmmmmmmmmm….. I’m suspicious of that.

I’ve used NPH in the past. It’s a little… unpredictable. It also has a waaaaaaaaaay shorter duration of action than the two “L”s. Still, something to keep in the Break Glass in case of Emergency box. I snooped around online and found press releases stating that ReliOn brand is made for Wal-Mart by Novo. In fact, all three Novolin insulins (regular, NPH, and a 70/30 mix) are at your friendly neighborhood Wal-Mart for the alleged price of $16.94 per vial. Wal-Mart reminds us that they have ReliOn syringes and glucose tablets too.

I was really impressed with Lujan. Not what you expect from an insurance nurse at all. I wondered if she was one of us.

Can I ask you a personal question?

Long silence, then, “Sure.”

Are you a diabetic?

“No, I’m not, why?”

Well you’re doing such a great job for us, I figured you must be one of us. I’ll tell you what, I’ll make you an honorary diabetic.

Laughing, “I’m honored…. I think. At least I’ll have something to tell my family when I get home tonight.”

Congratulations, you’re now a member of the tribe. We’ll get you your T-shirt and Glucometer later.

Don’t leave home without it: your American Express Card and your Insulin

I needed a fasting blood draw. So no pills, no breakfast; but black Starbucks Rift Valley coffee is OK. My co-workers know better than to mess with my coffee.

After 5 months, I finally paid off the lab bill from my last round of blood tests. Now that my credit standing is restored with the hospital’s lab, I can finally do the next round of over-due blood tests. It never ends. Sigh.

We want to see if my thyroid and my Synthroid are still getting along. I’ve been draggy, but I don’t sleep enough and I worry too much, so it’s probably unfair to blame the lumpy little gland in my throat.

We want to see if my liver is happier with the Lipitor, or if my numbers are still getting worse. While we’re at it, we want to see if the Lipitor is doing its job of lowering my Lousy Darn Lipid. New research show’s we D-folk might live to be as old as anyone else if we could get our LDL under… gulp… 70.

We want to see if the ACE is helping my kidney’s, or if they have gotten worse too.

Of course, we’re running an A1C, which most likely won’t be pretty.

The night before I laid out a spoon and a little bag of walnuts. The plan was to grab some sugar-free yogurt on the way out the door, for a late breakfast after one of my colleagues drew a Lavender tube, a Red Tiger tube, and a Green Tiger tube from a vein on my “AC.” That stands for…. Well crap, I’ve been out of school so long I don’t remember what it stands for, but it is the opposite side of your elbow where all the juicy veins lie just beneath the surface.

So just before the doors opened, “E” stuck me with a Butterfly and drew the tubes. She had the bad luck to get the tip up against a valve. It was slow going, but not slow enough to justify a second stick. As I walked out of the clinic’s lab to get my yogurt I remembered that it was still sitting in my fridge almost 80 miles away. Crap. Got the spoon. Got the walnuts. But no yogurt.

The sun up, but still cold at over 7,000 feet above sea-level, I scoot across the parking lot to the “Annex,” the small grey construction trailer left over from building the clinic that is now home to the diabetes program. I’m hoping my assistant has the heat on. Despite my best efforts, I can’t make her understand how a thermostat works. When she’s cold she slides the needle all the way to the right; when she’s hot she slides it all the way to the left. It probably makes no difference, it’s one of those buildings that’s either too hot or too cold anyway.

Nice and toasty in my office, I open my fridge to grab a Slim-fast Low Carb Diet shake. I slide my Go-Bag off my shoulder to grab my grey pen and…. Where the hell is my insulin pen? Then, in my mind’s eye, I see it. It is sitting on the kitchen table 80 miles away. It’s been there since dinner last night. I normally hook it to my bag after breakfast, which I didn’t have today ‘cause of the blood draw. Double crap.

Well, at least I work at a place with a pretty good supply of insulin. Thank God I don’t work in the Dove Chocolate Factory. I stick my nose back in the fridge to review my samples. Triple crap. I gave my last Lilly sample pen away last week to a “between jobs” Type-1 who was having real problems affording her insulin.

I dash back across the cold parking lot to the main clinic. I short-cut through the administrative offices and enter my magic code to open the pharmacy door. We’ve recently added Humalog to our formulary through a special program that makes it not only affordable, but a hell of a good deal. My co-pay from Pres is $55 for a one-month supply. Now I can buy it at the clinic, out of pocket, cheaper than that. (Yes, I’m directly responsible for this program as a direct result of the near-heart attack I had the first time I was told my co-pay was $55. So I was not only able to help out the uninsured, but the sub-insured like myself as well.)

I snitch a pen out of one of the five-pack boxes, promising the pharmacy guy to replace it with one of my own the next day.

Back across the cold parking lot to my office, which is now roughly the temperature of Aruba in July. Hey, swing the little lever on the thermostat to the left. No, no. Left… Izquierda.

Pop the pen cap off. Tear backing sheet from pen needle. Screw it on like the cap on a tire. Pull off cover and throw it to floor. Oh wait. No cat here to play with it. Memo to self: pick up the damn cover so no one slips on it. Twist, pull, click-click. Remove needle sheath with teeth, slip needle into skin—tiny little 31 gauge needle, no pinch up required. Depress plunger smoothly with thumb and……..Owwwwwwwwwch! Oh damn! I forgot how much cold insulin stings.

So that’s the reminder lesson for today. Veteran D-Folk often still keep their insulin in the fridge out of habit from the old-days when you had too. If you are using any of the modern analogs (Apidra, Humalog, Novolog, Lantus, or Levemir) you don’t need to keep it cold once the vial is breached or the pen capped with a needle for the first time. Keeping it cold doesn’t extend the life of the juice and sure as hell makes your life worse. Clarification: of course, keep your unopened vials and pens in the fridge until first use.

I take a sip of the shake. Yuck. Vanilla. They were out of creamy chocolate at Sam’s Club this last time. Time to start the day. I type in my username and password and call up my schedual. Pumpless. Insuinlinless. Liquid breakfast. Thank God being a bad example is just as powerful a teaching tool as being a good example. I don’t think the words “role model” are likely to be part of my eulogy. I’ve got 15 folks coming in today. I’ll tell them what I did, make fun of myself, and remind them not to keep their juice in the fridge.

Tomorrow the lab will FAX us the results of the blood tests. In about six weeks I’ll get the bill, and I’ll have to call the hospital billing department and arrange a payment plan. The cycle of medical economics and the accompanying functional poverty begins once again. Not quite as romantic as Disney’s Circle of Life in the Lion King; but the reality we all live under in our country whose leaders espouse a “culture of life.”

The family love of books

“That’s awful,” said Rio, truly shocked, “all houses should have a library full of books to read.”

I agree with you, but the fact stands that it is unusual. Rio had just discovered that not every house in the world has a library. Just houses he’s been in. Or come to think of it, houses I’ve lived in.

When I was a kid, living in Durango, Colorado, we had a huge living room. All across one long side was a massive floor to ceiling bookcase that housed the family books and my Mom’s collection of Native American pottery which we drove out to the Pueblo’s in person to barter for.

When I was a teenager I lived in the basement of my Mom and Dad’s condo, now in Northern Colorado. When we moved in the basement was only about half finished, so as a reward to being banished to an area with no windows (probably why I live on a mesa top with unrestricted 360 degree views to the horizon) I was allowed to have some influence on the final design. My room had a combined darkroom and bathroom on one side, a main room with a cork-board wall floor to ceiling, a water bed, a hammock, and a giant military surplus oak desk for my tiny traveling Olivetti manual type writer, and on the other side a converted walk in closet. The conversion was shelves lining both sides top to bottom and full of books. It was my first library.

When I went off for several sad years of college (not finished until adulthood) my various apartments featured book cases made of “librated” grey plastic Lucerne milk crates. I was at the Grand Opening of a Container Store in Colorado about a month ago and they now sell designer “milk crates” for, like, 49 bucks. I had no idea I was such a trend setter back then.

Post college, as a working photojournalist, my various apartments featured waaaaaaaaaaaaaay more book cases than the average man; some of wood, some still the grey plastic. I lost the big desk somewhere along the line. Probably my friends threatened to never help me move again if I didn’t get rid of either the desk or the books.

Our house of the last two decades started it’s life as a small 40’ double-wide mobile home. I say started, ‘cause it’s been added on to a number of times and isn’t going anywhere ever again. We choose a floor plan of a model we pretty much liked and started making modifications. The first thing I insisted on was the library. The design called for a master bedroom on one side of the house, a combined kitchen-dining room and living room in the middle, and two smaller bedrooms on the other side of the house. One of the small rooms became the library. We moved the door, replacing it with French Doors to the living room and got rid of the closet. I hired a local drunk carpenter with a good rep for craftsmanship to build floor-to-ceiling book cases for three walls of the room. He staggered the vertical support braces to create visual interest and sections of various sizes. The shelves on the bottom are taller for large books and the ones towards the top shorter for smaller books. Let’s you maximize the space. It also had a rolling ladder that never really worked right but looked great.

All this was built based on the measurements on the “blue print.” When the two halves of our house arrived at the dealer’s lot from the factory, our master builder delivered the sections of the library so they could ride inside the house during it’s final twenty mile journey to our land. Once the house was set he came up and set it all up. It fit perfectly. Never occurred to me at the time that it wouldn’t. I’d be a nervous wreck if I had to do it over; enough things have gone wrong in life since then that I’m quick to see the worst thing that might happen.

The other small room, now Rio’s headquarters, was originally a darkroom. In the early 90’s the lab business outgrew the house and got it’s own building.

Rio’s Grandma Jean’s house “in the sky” has a floor to ceiling book case all a long one wall of the living room, plus two more book cases. His recently deceased Big Grandma’s house had a room-dominating bookcase surrounding the fire place in the living room. Some of those books have now come to live with us and we’ve run out of space. Books are overflowing to other parts of the house. Rio has his own library of sorts in his room: two six foot book cases in one corner filled with books, DVDs, and assorted toys that have no other homes. Anyway, poor Rio had no reason to assume that all houses didn’t have libraries. It was quite a shock to him.

I had originally organized our library by subject. So all the fiction was over here. All the anthropology, archeology, and sociology was over there. Classics up there. Photography books down here. Criminology on the right. History all across that part, and so on. Then one day Debbie reorganized based on the color of the spine. Looks much better, but I’ve never been able to find anything since. Oddly, the cook book section stayed intact. Hmmmmmm…..

Well, I know all of that had nothing to do with diabetes. Or did it? It is important to remember that we are all living, breathing, human beings with a wide range of interests and activities. We are diabetics, and that takes up a lot of our time; but first and foremost, we are people.

See you Monday with lots of other interesting D-stuff including the Honorary Diabetic, what happens when you leave home without your insulin, and a Khaki update.

The rest of the story

Khaki attacks my feet with a four-pawed pounce, presumably under the mistaken assumption that mice are hiding under the comforter. Wind whistles through the crack in the window, the sun is up, but it is cold.

It must be morning. Thank you God for another day.

Eyes half open, I feel around under the covers for the Guardian. The ten units wasn’t nearly enough. I’m closing in on 400. I find my glasses, lying on the floor, untangle the covers and make my way barefoot to the kitchen. I uncap my grey, slip the needle sheath off, spin, pull and click-click- click-click- click-click- click-click- click-click my way up to ten units. I pull up my wrinkled sleep shirt and slide the needle into my skin and inject the dose with my thumb; I hold the pen like some kind of suicidal manic ninja about to commit hari-kari.

Still in my underwear and sleep shirt I wander into the library to check email and E-bay. To my own woe I’ve discovered that there are over 5,000 tobacco pipes on E-bay at the moment and at least 500 of them would find a very good home here. Now usually, when I get obsessed with looking at stuff on E-bay it’s cameras or something else I can’t really afford. The problem with pipes is you can afford to bid on them. Lots of them. Thank God for E-snipe which lets me treat buyer’s remorse proactively. I log on and delete all the late night bids I placed yesterday. No one is any the wiser.

Beep-beep-beep. Fall rate.

Have you even noticed that morning highs are more fragile? It takes less insulin to knock them down.

Beep-beep-beep. Fall rate.

Beep-beep-beep. Fall rate.

Beep-beep-beep. Fall rate.

This can’t end well.

Guardian now has me down to 128. Time for a finger stick. The drop is soooo steep that it doesn’t even graph as a line, more a series of disjointed dots.

I reach for the Abbott Precision Xtra meter that lives on my desk. I’m not necessarily partial to Abbott products, it’s just that they make about 68% of the stuff we use. The P-Xtra is an older meter that is under-rated. It’s actually one of the best T-1 meters on the planet. It is small, light, and ergonomically designed to fit comfortably in the hand (flaring outwards towards the top). The read out is LARGE. It has a backlight. It is fast, fast, fast. It does use a larger drop of blood, but I’m not sure that’s a bad thing. I’m always a bit paranoid by the itsey-tiney-bitty drop the Freestyle meters use. But most important of all, with a special test strip, it can test for blood ketones. If you are T-1 and you don’t use this meter, you should at least own one for that purpose.

It also downloads to Co-Pilot, the best D-software on the planet.

The only down side to the meter, for some folks, is that the test strips are indiviaully foil wrapped. While this does keep each one in prime fighting shape safe from moisture and makes them flat to carry; it does generate a lot more trash and I find it slow. That said, one of my Peer Educators who has peripheral neuropathy reports that he can’t fish a test strip out of a vial—he loves the foil wrapped strips. And I can’t count the number of times I’ve dumped an entire vial of test strips on the floor trying to get out just one.

The meter calibrates using a “stick” that comes with each box of strips, a Rosetta Stone that looks much like the test strips. I think that’s a good thing. The stick is there to remind you ya’ need to do it. The “enter the number” style calibrations on older Freestyle and One-touch meters don’t get changed with new vials more times than any of you can imagine. It is such a common problem that it is now the first thing we check when a patient comes in.

The meter clocks me in at 50 again. Crap.

I fetch the left-over yogurt covered raisins, and thoroughly disgusted, I start eating them while I write this. Even with the best of gear, being diabetic is never easy.

Nocturnal low

Dateline—3 a.m.
Blood sugar 52 mg/dl

Guardian didn’t wake me.

Neither of my Type-3’s woke me.

The cat didn’t wake me.

The sweat woke me up.

I’m drenched, my shirt wet and cold, clinging damply on my shivering skin. With shaking hands I do a fingerstick using Abbott’s new rubber-backed Freestyle Lite; the Queen of the Night. She uses self coding strips and features a large readout with a bright white “strip light” that lets you test in total darkness.


I stare dumbly at the number the Queen reports, trying with a muddy brain to process the fact that my blood sugar is dangerously low. I fumble blindly for my jar of cherry slices; my default cure for hypos small and large. I get the lid off the jar, my hands now shaking. I fumble one piece out of the jar and try to eat it slowly. Then a second. That’s about 20 or 25 carbs now. More than enough. I could go back to sleep and wake up in the morning.

But riding on the wind with the Hypo comes it’s dark partner: Fear.

My IQ roughly equivalent to my blood sugar, I stumble to the kitchen, half blind, my glasses who-knows-where. In the pantry I find an unopened sack of yogurt covered raisins. I zip off the easy open tab, but my hands are shaking too much to get the sack open. I cut closer to the re-sealable zipper with the kitchen scissors. No luck. Damn these Fresh-Lock (a registered trade mark of the Presto Products Company, no shit) containers! I wonder how many diabetics have died in the night trying to open Fresh-Lock sacks to get to carbs?

In desperation I try tearing into the sack using my teeth. No go. Tough stuff, these Fresh-Locks. Finally, I eviscerate the sack with the scissors and begin stuffing the raisins greedily into my mouth. Next comes cookies and corn chips. Between the two bowls of Apple Jacks my IQ crosses the 100 mark and I take 10 units of Humalog from the grey pen. I know the rebound excursion is coming.

Then I collapse back into bed. My heart is pounding in my rib cage. A frantic animal trying to escape it’s cage as the ship sinks. A double pulse. THUMP-tump. THUMP-tump. THUMP-tump. THUMP-tump. THUMP-tump. THUMP-tump. THUMP-tump.

So heavy and strong I can almost hear it. Am I having a heart attack? Is it the huge surge of sugar coursing through my veins? Is it the adrenaline of fear?

A sign for the times

Rio is learning about signs in Kindergarten. Last night, as we were unwinding from the day on our back porch, R shared some of his knowledge.

“There’s a sign that says ‘open’ or ‘closed’ on a businesses so that you know if you can spend some money there. Like if Daddy wanted something. Or Momma wanted something. Or maybe if we needed to get a little toy for Rio.”

That’s true baby.

“And there is another sign that says ‘Beware for mean dog.’”

That’s a good sign to know how to read.

“And,” he said, extending his hand out flatly, fingers spread, “there’s a sign that says STOP!”

Also true.

After the sign dissertation I took 25 units of Levemir. It was a bad night requiring a couple of hits of fast acting carbs. I woke up at 74 but was in the mid 60s by the time I got some Muslix poured into a bowl. I had intended to eat something more carb-friendly, but at this point some dried fruit was sounding like a good idea. I took a baby hit of Humalog, grabbed my coffee and checked my AP headlines at Yahoo.

20 minutes after eating it was time to get Rio up and to kindergarten. The SG was still sluggish and low. Damn.

I bundled the punk up, the mornings are getting cold. I strapped him into his car seat and he pulled a sheet he brought from his bed over his head. Like his mother, not a morning person.

Zipping north to town, passing through rare fog banks, I’m still showing a low SG on the Guardian. I decided to double check my sugar with a fingerstick. I slip a Accu-Check Aviva out of the sunglass holder in my wife’s aging CRV. I unzippppppp, pop open the vial and slip a strip out. Into the port. I lance my finger with a One-touch Mini lancer (best ever made, works one-handed or strapped into the case).

Beep! BG is on the rise at 74. Good.

Voice from the back. “Remember we were studying signs in school, Daddy?”

Sure, I remember. Why?

“I just saw a sign that says ‘No checking your blood sugar while you’re driving because you might lose control of the vehicle and crash down.”

I don’t recall seeing that sign.

Oh. Wait. There it is:




(base image pirated from Everydayhealth.com)

Insurance isn’t

In other happy news UPS just brought me another foam sarcophagus. This is my SECOND box of sensors subsidized by my almost-worthless insurance. This Red-Label box arrived nearly three weeks after I ordered it. Seems MedT is having trouble keeping up with demand for their sensors. This could be a huge set-back for our fiends in California. It’s not like falling short on the manufacture of insulin, which would actually kill people, but not being able to make enough devices that chronically ill people depend on to stay healthy is a serious problem.

At the clinic, I spent months fighting Medicaid to get a particularly hypo prone T-1 approved for a Guardian. I finally got it approved then MedT tells me that they don’t even know when they’ll be able to ship. Could be a month!

Turns out this box, and the one before it, will actually set me back 175 bucks each, not the $161 I was told it would. It seems the insurance company’s negotiation on price is only for their half of the sensors. I still have to pay half of the full retail price. So screwed yet again.

What perverted world it is where the insurance company makes the co pay and the patient pays the balance?

So now I pay $17.50 per sensor. I guess that’s a real bargain over the $45 each I paid way back when this adventure began almost two years ago. The price of being a pioneer, I suppose. If I wear the sensors as indicated it would cost $5.84 per day or $2,132 per year with insurance coverage.